In 2019, Covid-19 hit the world with a force that brought unprecedented changes within the healthcare. Not since the Spanish Flu pandemic of 1918 ± that affected one-third of the entire population globally over the period of one year. Pandemic posed a significant challenge to the healthcare system that necessitate vital strategies during the outbreak, especially in treating critically ill patients. The rapid spread of this virus poses a serious threat to human health and is having a significant influence on public health, global communications, and economic systems around the world. Nurses play an important role in healthcare teams that are tasked with controlling and preventing the spread of infectious diseases. Nurses also work on the front lines, providing direct care to Covid19-infected people. Nurses role and functions were health education, screening services, and support for the general public and for individuals in high-risk categories, infection prevention and surveillance, implementing appropriate preparations and precautions in nursing home and long-term care settings, protection of patients with immune deficits or underlying diseases such as chronic obstructive pulmonary disease, chronic illnesses, and cancer (Chen et al, 2020).
Nurses have a pivotal role to play in the management of Covid-19. Their role starts from the initial history collection, triaging, sample collection, drug administration for symptomatic management such as acetaminophen for fever and malaise, antibiotics for associated bacterial infection, and oxygen administration to maintain Spo290%. Other important activities that nurses perform include meeting patients personal hygiene, guiding them to take plenty of fluids, balanced diet rich in proteins and vitamins, and infection prevention and control techniques. Nurses interventions for critically ill patients include advanced airway, mechanical breathing, intravenous fluid delivery, vasopressors, and nasogastric/parenteral nutrition (Sharma et al, 2020)
Be it in daily routine or disasters, nurses are on the frontline, and are responsible for providing holistic care for all types of patients. Considering the fact that nurses constitute the majority of healthcare providers, they have a critical function in healthcare systems. Their role in treating patients with Covid-19 involve triaging patients and detecting suspected cases with infections; providing essential treatment in an emergency and dealing with suspected patients with precautions; helping in decontamination and coordination with other healthcare providers; supplying holistic nursing practices in managing multiple infections simultaneously; playing critical role in expanding care services; and dealing with patients's, relatives. Apart from the stated ones, nurses expanded their reach and went beyond to deal the pandemic.
Objectives
The study aimed to:
Review of Literature
Thomas (2021) discussed the transitioning role of nurses during the pandemic. Earlier they underwent considerable anxiety, later the challenges were easy like the duty strengthened pharmacology knowledge of nurses by applying critical thinking skills to understand pharmacodynamics of the drug regimen. Nurses collaborated with physicians to taper the dose, and stopped the drugs when side effects were observed like bloody stool for lowmolecular-weight-heparin. Additional treatment regimens were given to the patient along with alternative therapies like yoga, rajyoga meditation, counselling, recreational activities along with routine care like deep breathing coughing exercises, spirometer exercises, balloon exercises etc.
Munoz-Price et al (2022) reported that during the pandemic, the role of nurses evolved from simply caring for the sick to focusing on recovery. Consequently, they needed comprehensive knowledge and skills to effectively address the outbreak and handle critical situations. Nurses in intensive care units, emergency departments, infection control, and general wards were particularly at risk of contracting Covid-19.
Materials and Methods
A descriptive cross sectional survey research design was used. A total of 664 nurses (after power estimation) including Nursing Officers/ Staff Nurses (n=403), Nursing Supervisors (n=39); and remaining were Nursing Superintendent, Chief Nursing Officers, nurse educators, teaching faculties of nursing, nurse coordinators and other specialty nurses participated in the study. The study subjects were recruited through purposive sampling technique. The study was conducted in primary health care settings, hospitals (private, government, missionary), exclusive Covid care centres, quarantine centres, Covid screening centres, Schools/Colleges of Nursing, telemedicine centres. The registered licensed nurses who were involved in Covid care in various capacities with educational qualification of ANM, DPHN, GNM, BSc(N), MSc(N), PhD were included in the study. Tool of the study was developed on the basis of literature review from national and international journals, web search engines like Scopus, PubMed, Science direct, Medline along with consultation of medical experts and experienced nursing clinicians as well as the observation by the authors. The tools consisted of baseline variables of Nurses including age, professional education, gender, marital status, number of children for married, family type, designation, experience along with Covid duty-related data such as number of months involved in Covid care, area of Covid duty, post-discharge follow-up of pateints, duty hours, vaccination.
Structured questionnaires were also developed based on the domains such as emerging role of nurses after Covid-19, roles related to crisis management, roles related to leadership skills and challenges faced by nursing professionals during Covid-19. Each domain had questions with responses of very often, often, sometimes and never. Further, six open-ended questions were asked in relation to Covid and its impact on nurses, personal and professional life, strategies adopted by Nurses at work place, home and public places to mitigate its spread, non-pharmacological measures adopted by nurses, mental health and Covid-19.
The tools were validated by 11 experts in the field of respiratory medicine and clinicians in terms of its criteria met, partially met, not met. Content similarity index (CSI) was 94 percent. From the pilot study of 50 nurses the reliability of tools were established. Reliability of the tool was estimated using Karl Pearsons Corrleation Coefficient formula, in which reliability was 0.89. The study was approved by Ethics Committee of Clinical Nursing Research Society. Informed and written consent was obtained from each participant with assurance of confidentiality and anonymity through google link. Data collection was done through google link using structured questionnaires and interview was done with few samples also for analysing open-ended questions. It took 4 months to complete the data collection (1 February to 31 May 2022). The analysis was done using descriptive and inferential statistics. Openended questions were analysed thematically.
Results
Baseline Variables: Majority of staff nurses (68.7%) were in the age group of 20-29 and more than half (57.1%) of the participants were graduates in nursing. Females constituted about 83.9 percent of the sample; 48 percent of the staff were married, the majority of the staff (57.2%) belonged to nuclear families and the primary place of stay was home (73.6%). Majority of staff (63.6%) took care of the elderly at home, about one-third (35.3%) of the staff were feeding mothers, more than half of the staff (62%) were currently working in private/ corporate hospitals, the location of the institution was mostly urban (64.9%). Majority of the participants (60.7%) were Nursing officers (n=403), whereas, a third (29.5%) of the had less than 1 year of experience. More than a third (39.9%) had worked in Covid areas such as Fever clinic, wards, ICU and emergency room for at least 3 months. About 42.5 percent of the staff worked in Covid wards. The majority of the Nursing officers (63%) stated that they have done post-discharge follow-up. The number of staff who got infected with Covid was 64 (39.8%) which is a significant number. The number of staff who were vaccinated against Covid were 98.2 percent of the whole sample. About 76.8 percent of the staff worked for 6-8 hours during Covid which was the maximum.
Role Transformation of Nurses during Covid-19
About half of the nurses (50.3%) expressed that they were able to take on a moderate level of Emergent role of nurses after Covid-19, and more than half of them (58.5%) had a moderate score in roles related to crisis management and 42.3 percent had moderate score in roles related to leadership skills (Table 1).
Nurses had highest mean (SD) score (13.37 α 2.99) in crisis management followed by emergent roles (10.55 α2.86) and leadership skills (5.77 α 2.31) respectively.
Responsibilities of Nurses after Covid-19
Majority of the nurses (33.7%) were sometimes doing screening and triaging of Covid patients, 33.6 percent were sometimes performing life saving measures, 39.5 percent were very often following standing orders and 31.6 percent of nurses were sometimes using complementary and alternative medicine (Table 2).
Responsibilities related to Crisis management roles of nurses after Covid-19:Majority of the nurses (41.4%) were sometimes faced changes in duty hours, 56.8 percent were very often provided with adequate PPE kit, 32.5 percent nurses sometimes felt social discrimination, 31.2 percent nurses sometimes able to avail the employee benefits and 33.9 percent were sometimes able to follow the End-of-life care policy for the Covid Patients (Table 3).
Leadership roles of Nurses after Covid-19:
Most of the nurses (n = 482, 72.6%) were involved in the development of policies and procedures of covid 19, more than half (n = 359, 54.1%) were involved in clinical committees regarding decision making, about 75.7 percent of the nurses could avail adequate rest, recoup and safety measures for the nursing staff. More than half (n = 347, 52.3%) were empowered to report unusual incidents pertaining to self and patient safety, only 50.5% of the nurses incorporated creative idea in order to reduce fear and anxiety amongst patients and colleagues, majority of the nurses (n = 614, 92.5%) were well prepared to take care of Covid-19 patients, only few (n = 293, 44.1%) of the nurses had participated in any clinical trial during Covid-19 phase, most of the nurses (n = 587, 88.4%) used to get updated guidelines issued by WHO/ICMR/MOHFW and nearly 48.2 percent of the nurses participated in any committees like Covid guidelines preparation, crisis management of shortage of nurses etc at National/District/ Corporate/Panchayat level.
Table 1: Level of role transformation of nurses during Covid-19 (n=664)
Table 2: Challenges faced by Nursing professionals in Covid-19 (n=664)
Association of Role Transformation with Selected Baseline Variables
Table 3: Association of Role transformation with selected baseline variables
Analysis of Covid-19 and its Impact:
Six open-ended questions were also asked in relation to Covid and its impact in Nurses personal and professional life, strategies adopted by Nurses at work place, home and public places to mitigate its spread, non-pharmacological measures adopted by Nurses, mental health and Covid-19. The themes emerged from the data are mentioned below.
Challenges in Personal Life
Separation from family: 80 percent of the study subjects reported that they were more concerned about their family members and others. They expressed being away from the family during Covid duties in the 1st wave were very difficult and struggling days.
I could not meet my parents since 2 years. I was anxious about their physical health. (Participant 75)
Changes in life styles: I personally feel sometime as lost. My complete life schedule got changed. I am unable to concentrate on my personal needs especially my diet, my physique etc. complete life style got changed due to continuous and hectic Covid duty. (Participant 33)
Challenges in physical health: Many things changed after Covid pandemic. After such a hectic duty, there was no sufficient time to take rest and I was not physically well. Two times I got admitted for Covid positive which was really worst part of my days (Participant 62)
Impact on mental health: I have never seen death of patient like this which was very horrible for me. In a day, so many deaths occurred which was really a mental frustration for me. Patients were dying in front of us as very helpless. We could not save many patients. They were dying without their families presence. I do not want to think of those days which was very upsetting and dreadful for me. (Participant 186)
Impact of Covid in professional life
Disturbance in work schedule and routine: There was many patients in my ward. Sometimes I was told to do long duty for 12-14 hours which was very tiresome. Due to sudden changing in the plan of duty hours, I could not focus on my personal needs. (Participant 62)
Challenges in wearing PPE kit: I had very much discomfort when wore PPE for 8-10 hours. I was unable to drink water even sometimes with PPE kit. Being a female, sometimes I suffered difficulty in going washroom with PPE. (Participant 71)
During first wave, we were given very low quality PPE where we were very much prone to get infection. It was very heavy for me and due to profuse sweating, I got dehydrated and collapsed during duty. (Participant 202)
Hectic workload: 91 percent of the participants faced heavy workload due to shortages of nurses and doctors. Nurses were working for long duty shifts especially in private sectors.
In my hospital, Nurses were facing high work pressure. I could not avail night off also after working for 6-7 nights. Due to shortage of nurses in my hospital, we were allotted multiple task duties especially admission, investigation, medication administration, sometimes patients personal needs as their bystanders were not allowed etc. (Participant 12)
Lack of resources: Lack of sufficient resources and facilities were experienced by 88 percent of the participants during Covid duty. There was no adequate resources in our hospital, somehow we got PPE kit, but there was no adequate room for Nurses to rest, no sufficient nurses and doctors, no food facilities and many more were lacking. (Participant 19)
Extended role of Nurses during Covid
During Covid duty, the Nurses were able to enhance their professionalism by extending more competent Nursing care to the patients. The subthemes that emerged under this theme were proactive role of nurses, non-pharmacological measures and promotion of mental health.
Proactive Role of Nurses
During Covid-19, it was observed that there was a transformational changes in the nurses role from their traditional and routine to more and more proactive roles. Nurses were taking leadership role very effectively during the unprecedented situation like Covid. Despite the challenges, Nurses were able to manage the patient very competently and effectively.
At present, I feel more proud as a Nurse as everywhere nurses were recognising a lot. We could able to provide competent holistic nursing care to the patient. Sometimes in the absence of doctors, we Nurses were managing the whole unit starting from their admission, investigations, treatment, their discharge etc. Being proactive in my role, I could experience a drastic change in my responsibilities and professional commitments. (Participant 559)
Non-pharmacological measures adopted by nurses
Apart from the routine pharmacological measures and other remedial measures, nurses were able to adopt various non pharmacological measures and Nursing interventions to mitigate Covid-19.
Compassionate care: My life view changed just before Christmas when I got Covid-19. I was utterly shocked and kept asking how could I fail at observing the prevention protocols. Now I truly understand the psychological and physical meaning of living with Covid-19. Not everyone is fortunate to have ready access to social services, so I am fortunate. The Covid duty experience provided me with further compassion and determination to keep doing the best to ensure less fortunate citizens get access to the right information and services that can save their lives. (Participant 478)
Promotion of mental health of patient:
Nurses performs a pivotal role in promoting mental health of Covid patient along with their routine schedule. Consoling patients and making them to divert their mind from depression to happiness. Boosting their immunity by encouraging them to cope with the situation bravely. (Participant 115)
Professional Empowerment
Professional satisfaction, recognition and identity Covid strengthened to improve my attitude towards the profession. I was able to face the challenges during duty hours (Participant 54) I believe in receiving blessings from my patients and relatives which is far better than receiving any awards and recognitions. I was recognized by Covid warrior ward from District sub collector which was a positive appreciation which enhanced my self esteem. However I am rather more happy for the blessings and appreciation words received from my patients. (Participant 446)
Discussion
The Covid-19 pandemic had harshly demonstrated to the globe the vulnerability of health system. Nurses were led to the emergent critical roles and responsibilities during the Covid-19 pandemic as they are in the front line of patient care in hospitals and also actively involved with evaluation and monitoring in the community (Fawaz et al, 2020). The present study revealed that about half of the nurses (50.3%) had expressed that they were able to take on a moderate level of emergent role of nurses after Covid-19, and more than half of them (58.5%) had a moderate score in roles related to crisis management and 42.3 percent had moderate score in roles related to leadership skills. This moderate score suggests that the subjects had taken on a completely new role when the need arose during the pandemic and the possibility to advance further.
With regard to screening and triaging of Covid patients conducted by the nurses was done by one-third of the nurses (33.7%). This was further validated in a phenomenological study conducted by Mulyadi et al (2022) aimed to understand the experiences of ten nurses working in ED in Indonesia selecting and triaging patients during the Covid?19 pandemic. The ER nurses had experienced extreme challenges in triage, feeling of responsibility under uncontrolled spread and infection physical and psychological exhaustion, discovering strategies under difficult circumstances, looking for positive reinforcement, and optimism in togetherness. Nurses had to deal with the challenge of Covid ?19 in the ED triage, interestingly, the nurses have shown the development of professional responsibility. Nurses are also experienced in finding patient selection and triage strategies and the sense of optimism that may influence strategy and practice during the Covid ?19 pandemic.
During Covid-19, nurses were able to perform independent life-saving measures. Nurses reported that they performed life saving measures, sometimes (33.6%), by nurses while others did not get opportunity to perform them though all were willing to perform resuscitation following the revised protocol. An interesting finding from a survey conducted by Al-Shiakh et al (2019) found that among the multi-professional team on willingness to perform CPR for Covid patients included 18 nurses of which 55.5 percent were willing and 44.5 percent were not willing to perform CPR.
Nurses also work interdependently by adhering to the standing orders of the unit in the Institution where they worked. The nurses reported that standing orders were followed by nurses very often (39.5%), and only 31.6 percent of the nurses were permitted to use complementary and alternative medicine. Less than a third of doctor briefings about clinical conditions and 27.3 percent had direct communication, or accounted for more than half of the nurses methods of informing patients or their family of their clinical state (6.7%). Telephonic follow-up was the modality used for post-discharge follow-up after Covid, with (49.5%). This was seen in a similar study (Buheji Buhaid, 2020). In the present study, most of the nurses (72.6%) were involved in the development of policies and procedures of Covid 19, and more than half (n=359, 54.1%) were involved in clinical committees regarding decision making. Similar results were pointed out in a study comparing their usual care practices, nurses exercised greater autonomy in making clinical and pharmaceutical management decisions during Covid-19. Moreover, nurses actively participated in clinical decision-making during the pandemic. (Gonz__ampersandsignaacute;lez-Gil et al, 2021).
One of the key findings of the study was that very often the nurses were provided with adequate PPE (56.8%). These findings support the adequate availability of protective equipment. These findings are inconsistent with the findings of Razu et al 2021) where the participants frequently mentioned that the PPE provided by their hospitals was either insufficient or of low quality. Other studies also reported similar findings (Halcomb et al, 2020; Abuhammad et al, 2021).
Challenges faced can also lead to the emergence of new roles. This finding is in line with qualitative studies by Jia et al 2021 and Mohammadi et al (2022), carried out to examine the ethical challenges encountered by 18 nurses caring for patients with the novel Corona virus pneumonia (Covid-19) in China. The ethical challenges in nursing Covid19 patients and their positive coping styles have promoted the nurses abilities of clinical practice, decision-making, self-learning, coordination, and cooperation, psychological endurance, professional responsibility, dedication, psychological adjustment, adapting to role changes and motivation for achievement and establish a clear career path.
Problems were encountered by nurses with regard to availability of Personal Protective Equipment (PPE) during the Coronavirus Pandemic. The study found that 56.8 percent nurses reported that they were provided with adequate PPE. A survey in Turkey (Atay et al, 2020) on 307 nurses who actively cared for patients with Covid-19 reported problems such as sweating when wearing a surgical (50.9%) or N95 mask (64.2%), dry hands from wearing gloves (73.9%), perspiration when wearing overalls/ gowns (84.1%), and vision problems when wearing goggles/ face shields (47.9%). Length of use of mask for more than 4 years was associated with dryness of the cheeks, dry mouth, redness of the nose bridge, and redness of the ears for N95 masks and dryness of the mouth. Problems included skin dryness, sweating, and redness from wearing gloves; headaches from wearing goggles/ face shields; and sweating when wearing overalls or a gown ( 0.05 for all variables). The agencies should ensure availability and safety of PPE to protect the nurses. Other literatures also are in line with this data (Haegdorens et al, 2022).
Conclusion
The study found that 50.3 percent of nurses reported feeling capable of taking on a moderate level of emergency responsibilities following Covid19. Additionally, more than half (58.5%) scored moderately in crisis management roles, while 42.3 percent scored moderately in leadership skills. These moderate scores indicate that the participants adapted to new roles as needed during the pandemic, suggesting potential for further development. The study also highlighted the crucial roles of nurse administrators and clinicians in creating supportive environments and strategies, as well as providing psychological and social support for patients and healthcare workers. During outbreaks of new infectious diseases such as Covid-19, uncertainty, anxiety, and panic spread as the overall situation changes quickly, particularly while the disease is not yet under control. Supporting those with the disease, those under isolation, and healthcare staffs is essential, conducting studies on diseasespread prevention and the experience of supporting patients physically and psychologically will be crucial. Psychological distress and social burdens experienced by healthcare professionals and nurses during this outbreak will be vital as well. In order to achieve universal health coverage, every country must make investments in nurses and midwives.
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