Impact of Pandemics on Healthcare

Chapter 1

Background

Pandemics or biological disasters are the global spread of emerging and recurring epidemics of overwhelming diseases that affect many people and often cause mass deaths and financial and social disruption (Kisely et al., 2020). According to World Health Organisation (WHO) , ‘’ disaster is any incident that has ability to cause health-related harm or that could end human life and requires immediate response with sufficient workforce, resources, preparedness, planning and response’’ These pandemics are challenges for health care services and have impact on healthcare professionals, especially nurses who become victim as well as responders and thus, compromise patient care. There have been many devasting pandemics and epidemics in the world. The recent emergence of overwhelming infections such as “Severe Acute Respiratory Syndrome (SARS)” in 2003 (Maunder, 2004), swine flu in 2009 (Fitzgerald, 2009) and “Middle East Respiratory Syndrome (MERS)” in 2012 (Kim, 2018). Seale at al. (2009) points to the constant possibility of another global pandemic. The new coronavirus disease (Covid 19) identified in December 2019 in Wuhan, China illustrates the reality of that possibility (Kisely et al., 2020). A pandemic has a huge impact on the healthcare system and healthcare workers (Ives et al. 2009; Seale et al. 2009). At the time of writing, 163,087,661 coronavirus cases and 3,381,304 deaths were confirmed worldwide (https://www.worldometers.info/coronavirus/).

Ethical consideration

Ethical approval is an essential for most researches and research requires permission from the relevant ethic committee (Jirojwong et al. 2011; Elliot et al, 2012). Prior to the beginning of research, this research project approved by Ethics Committee of University, explained the aims and objectives and methodology of the integrated literature review.

Research Question

What are the nurses’ experiences of providing patient care during recent respiratory pandemic?

Aim of the Integrated literature review

The aim is to determine the nurses' experience of patient care during pandemics through an integrated literature review in order to inform future preparedness.

Research Objectives

To determine nurses’ experience of patient care with severe respiratory distress during pandemics.

To identify factors that nurses identify as important in contributing to their negative stress.

To explore factors that nurses identify as important to contribute to support managing their stress and support patient care for future.

To recommend the effective strategies that nurses can implement into their practices to get rid of their job-related stress and negative experiences of COVID 19 pandemic

Chapter 2

Methodology

Research design

This integrated literature is used to explore the experiences and challenges of the nurses working in the hospitals settings to give visibility to their work and support a plan to improve preparedness to care of patients with respiratory distress. The ILR method is an approach that uses diverse methodologies to comprehend information from diverse resources (experimental and non-experimental research) in order to understand of a specific phenomenon (Broome 1993). The advantage of using integrative literature review is that it provides an in-depth insight of the topic. The integrative literature review is referred to being as a traditional method in which critical, comprehensive and objective evaluation of the current existing knowledge regarding a topic is discussed (Schwebel and Larimer, 2018). Torraco, (2016) defined integrative literature review as an unique form to gain new information about a particular topic through reviewing, critiquing, and synthesizing of primary data in an such an integrated way in order to form new concepts for future research.

Search Strategy

Well- design and distinctive search strategies are critical in order to enhance the rigour of integrated literature review. Inadequate and biased searches has potential to give inaccurate results. (Cooper 1998, Conn et al. 2003a). In this ILR, the electronic search strategy was used for gathering information of the literature review. The benefits of using electronic search strategy includes cost-effectiveness and less time consumption in searching information required in executing the study and provide more refined and precise result and examine the ability of researcher to research online (Addison, Glover and Thornton, 2010). In addition, it also assists the researcher to avoid hindrances with manual search such as geographic barriers in turn creating opportunity to explore wide data from various countries for the determined topic for its enriched presentation (Amra et al., 2017). Moreover, it helps in lowering the error margin faced during manual collection of data in turn ensuring effective credibility of data presented by the researchers (McGuinness et al., 2019). Electronic databases are resourceful and effective, however, limitations cannot be denied with inconsistent search terminology and indexing problems may yield only about 50% of eligible studies (McGuinness et al., 2019). A comprehensive search with maximum number of eligible primary data is used in this review. The purposive sampling is combined with comprehensive research according to the research question. A structured electronic search was undertaken such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, Medline, Nursing and Allied Health Database, Cochrane Library, PubMed. However, during current ongoing respiratory pandemic, some publishers such as ‘Science Direct’ which uses Elsevier’s free health and medical research on current SARS-Cov-2 (Covid19) allows access to pre-published studies in order to combat this pandemic.

Inclusion and exclusion

In this ILR, studies published between 2010 t0 2021 were included. The selected studies were fully accessible, available in English Language, include primary and secondary data. Included studies involves empirical primary studies with qualitative research and mixed-method designs, focused on nurses, who engaged in providing direct care to the patients in hospital settings. The exclusion criteria to be considered for the study are papers that are not written in English, involves secondary data, non-academic, partially accessible. Studies focused on experiences of other health care professionals such as dietician, physiotherapist, student nurses etc. are excluded. The exclusion criteria are referred to the non-essential variables in the study which are avoided to be included as it leads to disrupt the study orientation by supporting inclusion of irrelevant data (Fernando et al., 2017). After specifying search, studies were included if they described nurses' experiences of direct patient care during a respiratory pandemic or biological disaster. According to World Health Organization definitions and terms, disasters, outbreak or pandemics were sorted, including SARS, avian flu, MERS swine flu and Covid19. Studies of nurses working during a pandemic to treat severe respiratory failure were included. Studies of nurses' experiences during an Ebola epidemic were excluded because Ebola was not a pandemic and had different means of spread. The selected papers focus on the research question regarding issues and challenges facing nurses during their response to care of patients during health crisis or pandemics. Studies, that showed experiences of community nurses were also excluded, focus given on nurse’s experiences in the hospital settings. Other reasons for exclusion included - lack of availability of separate data that focus on nurses only, only focus on nurses’ leaders and managements. After researches, generated total of 3145 citations, after removal of duplicates and irrelevant topics, a total of 85 citations were selected for relevance using title and abstract. Out of 85, 45full- text articles were retrieved for screening and 28 articles were further excluded. The reasons for exclusion was: as they were partially accessible, not focused on nurses, not in English language, focus on management aspects only rather than frontline nurses and were not eligible to provide detailed clear information require in critical representation of the data in this study. The remaining 17 articles were screened for their eligibility based on the purpose of this integrated literature review. No suitable citation/ articles were found on avian influenza. A total of 12 full text articles were selected for appraisal in the final review as they met inclusion criteria as they were focused on nurses’ experiences and challenges during their response to patient care during pandemics.

Keywords and Boolean operators

The keywords are main variables present in the study that structured the topic and enhance the representation of the content (Grant, 2016) also, called Search Engine Optimization (SEO). The benefit of identifying keywords in the research for search purpose is that it helps to create systematic research which leads in identifying valuable and relatable papers for the study (LibGuides, 2020). The keywords used in this literature review were- Nurs*, Nurse Or Frontline nurse, Healthcare Professionals OR Health Personnel Challenges , Perspective, Knowledge OR Experience, Nurse* And Barrier OR challenges, Ethical Challenges And Pandemic , Infection OR Pandemic , Respiratory Pandemic or outbreak, Coronavirus OR Covid19, SARS-CoV-2 Pandemic, Middle East Respiratory Syndrome OR MERS, Swine Flu. Nurse * And Pandemic, Nurse* and biological disaster, Nurse* And Stress, Nurse * And resilience, Nurse * preparedness And Pandemic. The Boolean operator are used in joining two or more valuable terms or synonyms in formulating a meaningful search leading to easier identification of relatable papers in the study (LibGuides, 2020) The Boolean operators such as ‘And’ and ‘OR’ are to be used to broaden or narrow a search in order to find the best evidence to answer the research question (LibGuides, 2020)

Chapter 3

Data extraction

In this integrated literature review, the data extracted from 8 qualitative and 1 mixed-method papers. In this review, studies published between 2010 and 2021 in different countries were reviewed The majority of nurses are females aged between 24 - 58 years. Years of experiences varied between 3 months (newly qualified) and 40 years (Galehdar et al., 2020). The experience of nurses has been collected from different medical environments and critical care units including emergency departments. The studies included in this literature review is summarized through a table containing, author(s) name, year of publication, place of study and key findings. All studies included qualitative studies and conducted with consistency Table 3 (Data extraction table) summarizes, the characteristics of 12 selected studies (8 qualitative studies, 1 mix-method study). Selected studies were published between 2010 (Corley et.al., 2010) and 2021 (Arcadi et al. 2021). Most studies were selected during recent Covid19 pandemic: Italy (Arcadi et al, 2021; Catania, et al. 2020), Spain (Fernandez-Castillo et al. 2021), China (He et al., 2020), US (LoGioudic and Bartos et al. 2020), Schroeder et al.2020), Iran (Grahledar et al. 2020; Moradi et al. 2020), South Korea (Kim, (2018), Hong Kong (Lam and Hung, 2013), Singapore (Koh et al. 2012), Australia (Corley et al. 2010), and were published in a reputed publication. In this ILR, narratives of 191 nurses, who provided direct care to the patients during pandemics, were included. Most nurses were female, age between 20- 64 years. Year of working experiences ranged from 2 weeks to 40 years. The studies were conducted in different hospital settings including Intensive Care Units (ICU), Emergency Departments (ED).

Chapter 4

Critical Appraisal / Quality appraisal

In this integrated literature review Critical Appraisal Skills Programme (CASP, 2017) for qualitative study was used to appraise the methodological quality of the selected 9 qualitative papers and 1 mixed-methods. Critical appraisal is a systematic process that helps to identify the strengths and weakness of primary research papers in order to assess the effectiveness and validity of research findings (Burn and Grove, 2011; Jirojwong et al. 2011). Critical appraisal is important to collate and synthesis all studies that meet eligibility criteria and helps to assess systematically the relevance in order to obtain reliable conclusions (Hannes and Macaitis, 2021; Dalton, Booth and Noyes, 2017) and applicable to healthcare settings (Wright-St Clair et al. 2014 to promote evidence-based practice. In this ILR, data were collected through interviews and video-calls. Based on the similar characteristics of the findings, the results were synthesized into themes and sub-themes. The Cormack et al. (2000) critique frame was, used to ensure a reliability, confirmability, transferability and trustworthiness of the articles and their importance for nursing and practice. In this ILR, all the primary research between 2010- 2021, have been conducted regarding experiences or perception of nurses for caring of patients during pandemics in global context. Papers generated from the search were from different countries that effected by pandemics. The titles of all articles were concise and focused on the contents. Most article are qualitative except one paper, written by Bartos and LoGuidice (2021) that is a mix-method study. Authors’ qualification and workplace were mentioned in all papers. All have Masters and Doctorate level qualification, thus, have clinical knowledge, experience and research expertise. All articles, starts with an abstract, which provides instant introduction to the readers about the purpose of the research, including aim, design/methodology, sample, data collection method, method of analysis, results and their implications in nursing practice (Cadwell, et al. 2011). All authors have successfully provided an appropriate justification for the approach, study design, findings or results, themes and sub- themes and implications in the abstracts of papers. All papers contextualised the research by introducing the readers to the experiences of nurses of caring of patients during pandemics. The rationale for the studies was based on a comprehensive literature research by the authors, that focus on the nurses’ lived experiences to provide patient optimal care whilst coping with a pandemic and how that had negatively impacted on their well-being. In almost all papers, the authors mentioned about the lessons learnt from these pandemics in relation to the nurses’ preparedness for the future, in global context, directly or indirectly. All these papers were focused on the issues, challenges faced by nurses during a pandemic. According to Cormack (2000), methodology provides a clear statement about the chosen research approach. Most of the research papers are qualitative and phenomenological in design. In all papers, the authors, clearly stated that they have used a qualitative approach to obtain thick description of nurse’s experiences, perceptions of working as frontline nurses during pandemic. Qualitative method is a distinctive method of research in its own right of specious (Sandelowski, 2009) and the field of qualitative is vast, however complex due to different methodological framework and theoretical models (Silverman. 2001). In all papers, authors clearly stated the rationale and justification of the methodology they used and the holistic nature of the papers (Kisely and Kendal, 2011). Most authors applied qualitative descriptive phenomenology, which is considered as ideal when there is limited research available. Also, quantitative studies, qualitative description gives meaning to quantitative data and has great importance of qualitative method in the research. Ethical approval from an appropriate body is essential for any research (Denzill and Lincoln, 2011). In this ILR, all papers were approved by local ethics committees and clear information was given to the participants, consent was gained from them and their availability was considered prior the interview. There is no evidence of any conflicts during data collection. The subject i.e. nurses experience is clearly define in all papers. The participants were selected from different countries and their inclusion recruitment was based on the key circumstances and characteristics such as age, work experience etc. Almost in all studies, there were purposive sampling for qualitative and mix-methods used by researchers, consistent with aim and objectives of the studies. The authors explained the nature and rationale for their purposive sampling in order to make the result more accessible to the readers.

There was difference in sample sizes in each paper. LoGiudice and Bartos (2021) had selected maximum 43 participants, Corley et al. (2010) selected 34 participants whereas Lam and Hung et al. 2013 and Koh et al. 2012 each selected minimum 10 participants. Data collection and data analysis of selected papers were based on semi-structured interviews, focused groups, open-ended questions, face-to-face individual to elicit experiences of nurses of patient care during pandemics. The use of semi-structured approach is considered as an appropriate approach for qualitative studies (Bazeley, 2009) as it gives in-depth exploration of participants’ viewpoints (Parahoo, 2006). The data were analysed through different approaches such as LoGiudice and Bartos et al. (2021) used qualitative content analysis and descriptive phenomenology by Husserl (Husserl, 1970). The thematic analysis, using different approaches such as : Graheldar et al.(2020) used ‘Lundman and ‘Graneheim’s approach’ whereas Corley et al. (2010) and Kou et al. (2012) used ‘Colaizzi approach’ and ‘Braun and Clarke approach’ respectively. Despite, using different approaches, all the authors were able to analysis the subjective interpretation of textual data into themes in their respective papers. In addition to this, some authors supported the summary with direct quotes of the participants such as Lam and Hung (2013); Moradi et (al. 2021). Therefore, increase the credibility of their research process (Bazeley, 2009). LoGiudice and Bartos (2021) used a convergent mixed-method (Creswell and Plano, 2018; Wisdom and Creswell, 2013) and analysed both qualitative and quantitative data separately in order to provide rigor result to validate the research question. LoGiudice and Bartos (2021) clearly discussed and focused on the choice of methodology (Cormack, 2000). The authors were collected quantitative data through Brief Resiliency Coping Scale (Sinclaie and Wallston, 2004) and to analyse qualitative descriptive phenomenology by Husserl (Husserl, 1970) using Collaizzi approach (Collaizzi, 1978). The choice of qualitative and quantitative method used by LoGiudice and Bartos (2021), clearly evident of greater rigour. There is clear evidence of hypothesis in the abstract (Pilot and Hungler, 2013; Nieswiadomy, 2012) that predicted clear relationship between two variables (Polit and Hungler, 2013) i.e. the nurses and their resilience. Further, the authors discussed thoroughly the sample selection of the participants on the basis of the requirement criteria as compare to any other authors, which could be considered a strength of this paper. The result of this study were presented in tables. The demographic data used by authors regarding nurses’ self-care was addressed to some level of understanding. The research may consider as Null hypothesis if this lack hypothesis content if there is no relationship between variables (White and Miller, 2014 and Wright-St Clair et al. 2014). The purpose of this mixed-study paper is to examine the experiences and resilience of registered nurses during Covid-19 pandemic. The researcher addressed the hypothesis by measuring nurses’ resilience level through ‘The Brief Resiliency Coping Scale (BRSC), rated on a ‘Likert Scale’(Wisdom and Creswell, 2013) and based on four items. Participants were rated their resiliency level on the basis of each item, and scored different scores- low resilient coper (4 to 13 points), Medium (14 to 16 points), High (17-20 points). The highest score demonstrated a participants high resilience level, whereas, low score demonstrated participant’s low level of resilience. The researchers established statical relationship between these two variables, and thus, addresses the question of the study by measuring and describing the results. In other words, used descriptive statistics to analyse the quantitative data for both BRCS responses demographic data, which is a quality of this paper. This paper is beneficial for further understanding about the experience of the nurses and their level of resiliency whilst working under extremely stressful environment and investigate the facts. Also, need evidence-based studies regarding to self-care methods to decrease their level of burnout and is important for future recommendations for practice. Overall, data collection and analysis of all studies were appropriate to for the purpose of research questions and aims of study. The results were presented in the forms of main categories or sub-categories / themes and sub-themes in their studies.

Chapter 5

Data Analysis / Thematic analysis

The thematic analysis is a method to analyse the data, extracted from the primary qualitative research papers selected for review. The thematic analysis allows the reviewer to show the systematic manner (Baker et al., 2018). In which the papers are viewed so that reader can see how the conclusion are drawn. In this process, initially the data is analysed to place them under respective themes to describe the information related with the study. Through a qualitative analytical approach, the core themes from the data developed and finally are presented in thematic framework. In order to synthesise, Thomas and Harden’s (2008) thematic analysis and synthesis approach were used to extract clear qualitative data by selecting studies, searching descriptive themes based on similarities of the selected papers, and by reviewing themes. The inclusion of thematic headlines strengthened the trustworthiness of the analysis. Thomas and Harden’s (2008) approach based on research question, purposeful sampling/searching, quality appraisal, key concepts in the study, developing themes, checking consistency of themes in all papers and translating concepts to generate themes. thematic analysis helps researcher to highlight viewpoint and main concept of each selected research paper thereby using these themes to discussion the selected research topic.

Table of themes:

Theme 1: Nurses feel prisoner in the fence of protective equipment:

Different studies on personal experiences of nurse shows that nurses have painful experiences while wearing the personal protective equipment (PPE) (Seale et al. 2009; Hope et al., 2011). Almost all the nurses are reported to face difficulties in providing the high-quality nursing care to COVID 19 patient due to the physical issues that they throughout the day under their PPE. After wearing these nurses experience reduced mobility, lack of ability to communicate with health staffs and patients, increased body temperature and suffocation. Evidence suggests that, there are many cases in which nurses whi suffers from COPD and others lung diseases, face severe breathing difficulties after wearing PPE (Fernandez et al., 2020). On the other hand, this PPE make the vision of nurses hazy which develop difficulties for nurses to perform the nursing task effectively such as checking BP, oxygen saturation and pulse COVID patients. Recent survey conducted on nurse response to the COVID 19 pandemic highlight the fact that nurses have to wear PPE till their shift is ended (Verbeek et al. 2019). There are several restrictions on eating, drinking, speaking, even going to bathroom for nurses and others health professionals after wearing {PPE). Most of the nurse experiences severe exhaustion due to heavy sweating under the PPE, which interfere with the ability to provide the high standard and compassionate care to the COVID19 patients. Evidence suggest that nurses have painful experiences of wearing the PPE for more than 12 hours during their shift which not only pose adverse impact on their physical health and wellbeing but also interfere with the psychological wellbeing, evidence suggest that majority of nurses across the world have reported to face severe depression, frustration, anxiety and even fear after wearing the PPE (Ranney, Griffeth and Jha, 2020). In this context, fore sake on improves the care delivery to COVID19 patients, health care authority needs to focus on how to reduce the stress and the negative experiences of nurses due to wear the PPE. In this case, nurses can be providing with some free quality time in which they can remove the PPE and work, eat ad speak freely in protective area. On the other hand, nurses must provide with some rest times which can boost their energy ad motivation for work.

Theme 2: Nurse experiences severe workload, job stress and burnout:

During this COVID19 crisis nurses have to deal with severe workload due to ever-increasing number of COVID19 patients (Fernandez et al., 2020). Throughout the care delivery to COVID19 patients, nurses have to work overtime (more than 12 hours) which not only pose adverse impacts on their physical health but also affect the mental and emotional wellbeing. By analysing nurse’s response to the COVID19 pandemic, it is seen that, for managing this health crisis, majority of the healthcare organisational are unable to maintain an effective task delegation system which pose severe workload on nurses. There are many cases in which nurses have to do over shift without returning to their home. Recent health survey has shown that, in last year, many cases have been registered in developing and under developed countries in which nurses have to stay in hospital throughout the week due to over burden of the COVID19 patients and were able to go back their homes on weekend. Throughout this pandemic situation, nurses have to deal worth manifold task that most of the time do not allow them to have a rest time and tiffin time (Gaheldar et al. (2020). In developing countries such as India, Pakistan, Bangladesh, the numbers of patients are increasing day by day as compared to the numbers of beds in the hospital (Taghavi and, Shali 2017). Therefore, many COVID19 patient are kept on the hospital floor due to scarcity of beds. Nurses have to put their best effort to manage the needs of these increasing numbers of patients each day which leads to sever nurse burnout (Catania et al. 2020). Thet WHO report shows that as compared to the numbers of health care professionals in hospitals the numbers of COVID19 patients are higher which poses server workload on nurses and doctors thereby posing adverse impacts on the the physical and physical wellbeing, on the other hand, as compared to doctors, nurses response towards the pandemic is pathetic because unlike doctors they have to deal with manyfold tasks which need high level of patience, effort and skills. After wearing PPE, it is not possible for nurse to maintain proper mobility and perform the manifold task perfectly therefore it interferes with their professional standard and care delivery skill. During this COVID19 pandemic nurses have to work more than they worked in the normal times. They have to observe the current health status of each COVID19 patient, then make the health report of each patients with accuracy, maintain effectives communication with the doctors regarding health status of COVID19 patients, observe the health deterioration of patients, maintain proper medicine administration and medicine management to ensure patients safety (LoGuidice and Bartos, 2021). In most of the healthcare centres of the developed and developing countries there are no pre-set work schedule for nurses. The schedule is changed every day based on the numbers of patients admitted on the day. There refire, in each day nurses have to be assigned with additional patients and their health issues, which pose extremes burnout and workload on nurses.

Theme 3: The emergence of nursing essence in managing the COVID-19 crisis:

As mentioned by Fernandez- Castillo (2020), nursing professional is intercalated with providing compassionate and high-quality care to service users thereby promoting the holistic wellbeing. Apart from many negative and painful response of nurses to their COVID19 pandemic, three are many nursing professionals who view this pandemic as the opportunities for them to understand the depth and essence of this profession. Recent health survey conducted by the WHO mentioned that, nurse responses to this COVID19 pandemic positively by stating that this pandemic teach them how to deal with any global health crisis. Many nurses reported that during this COVID19 pandemic they learn the importance and power of professionals in relation to provide the emotional and physical strength to the entire community thereby empowering the community against the pandemic situation (Catania et al. 2020). Throughout the care delivery to COVID19 patients, nurses have to manage several difficulties such as scarcity in the ventilation system, scarcity of oxygen supply system, lack on systematic delegation of task and poor multidisciplinary communication between nurses and doctors. Many nursing professionals view these difficulties as the opportunities to learn how to deal with all thte challenges in any pandemic situation. Evidence suggests that, managing the health needs of COVID19 patients although poses overburden of work on nurses, it also improves their decision-making, problem solving and critical thinking skill in relation to manage a perfect balance among different types of workload which will improve their professional standard as well as professional accountability (Fernandez- Castillo, 2020). On the other hand, this COVID19 crisis teaches nurses how to treat each COVID19 patient in relation to empower them by developing self-management and stress management skill in them. Nurses learn how to work with patience and common sense to accomplish each task by using the effective time management skill (Galehdar et al., 2020). They also learn how to use the empathetic words, love, caring approach and polite behaviour toward the COVID19 patients to improve their self-confidences and self-esteem. Throughout this COVID19 pandemic nurses work as the major frontline warriors who not only provide the holistic care and support to the patients in the hospitals but also empower the entire community by providing them with proper health education had health care advise (Corley, 2010; Kim 2018). Nursing profession is intercalated with empowering the entire community by improving the self-management skill that can assist the service users to have good control on their own health and wellbeing, during this COVID19 pandemic nursing professionals play crucial roles in providing advise to community people regarding which transformation as well as changes needed to be performed in their lifestyle to develop good immune system in them that can assist them to resist against the COVID19. Nurses provide proper guidance to the service users at the community level regarding which foods they need every day, what types of exercise they need of perform and how they would lead their life systematically and regularly to improve the biological system.

Theme 4: Nurses need to implemented early recognition and response system to meet health needs of COVID patients;

From recent report it can be stated that there are many cades in which COVID19 patient have to face sudden health deterioration and death due to delayed recognition and response to the health decline (Galehdar et al., 2020). In South Asian countries such as India, Bangladesh, Pakistan there are many cases of inpatients mortality in hospital setting due to the lack of care and clinical support to patients when they face the health deterioration. Different nursing professional’s response to the needs of early recognition to the health decline of COVID19 patients differently. Many nurses mentioned that, in this pandemic situation when there are ever increasing numbers of hospital admission of dying patients, it is not possible for the health care authority to provide immediate clinical support to all the patients as there is not that kind of medical infrastructure and resources in hospital that are needed for arranging immediate clinical support to COVID patients (LoGuidice and Bartos, 2021). On the other hand, many nursing professionals mentioned that lack of skill and knowledge of nursing staffs on how to deal with the sudden health declines of COVID19 patients are associated with delayed detection and response to health declines of COVID19 patients (Catania et al. (2020). The WHO (2020) mentioned in the COVID19 report that, in many hospitals and healthcare organisations, there are not enough ventilation system, modernised clinical machines which interfere with the ability of nursing professionals to detect the health declines of patient on time and arrange immediate clinical support to them. This is reason behind the increasing number of deaths in the developing and under-developed countries due to COVID19. Evidence suggests that for dealing with the COVID19 pandemic, healthcare authority needs to arrange all the resources that are required to conduct the early detection and response to the health deterioration as well as health needs of COVID19 patients (Moradi et al., 2020). On the other hand, nursing professionals need to be provided with proper training and skill development facilities that will enable them to develop the professional skills and ability that are needed to detect the health deterioration of COVID19 patients such as sudden reduction of oxygen saturation level and reduction of pulse or BP. Based on nurses’ response to the importance of an effective early detection and response system in hospitals it can be stated that, government needs to provide proper fund to all the healthcare organisations for installing the clinicals equipment and medical system that are required to provide immediate clinical support to COVID patients.

Theme 5: Nurses need support and psychological counselling:

While exploring nurses’ experiences to patients care in the COVID19 pandemic it is identified that nurses need psychotherapies and counselling for improving their emotional and psychological wellbeing (Moradi et al., 2020). Evidence suggests that, during the COVID19 nurses have to deal with severe workload and several work-related challenges that enhance their risk to different psychological illness such as depression anxiety, reduced self-confidences and lack of self-esteem. Recent data shows that, severe job stress and burnout pose adverse impact on positive decision making, positive thoughts and behaviour of nurses which interferer with their abilities to provide high quality care to COVID19 patients (Corley et al 2020). In this context, nurses need to provide with proper psychotherapies that will reinforces positives thoughts in them and motivate them towards their jobs. Moreover, regular counselling and emotional support to nurses assist them to improve the concentration, attentiveness and decision making. Stress management therapy is proved to be highly effectives in this COVID19 pandemic that assist nurse to remove exercise job stress. In additional to this, the senior health professionals such as doctors, senior nursing professionals and higher health care officials need to show cooperation, supportive attitude and emotional support to nurses which will assist them to deal easily with health needs of COVID19 patients.

Theme 6: Nurses face difficulties in managing first lines work during COVID 19 pandemic

Nurses face several difficulties while working as frontline clinical workers. Evidence suggests that most of the nurse’s face challenges such as lack of sufficient health care staffs, lack of trained health and social care professionals, lack of support and assistance from the doctors and senior nurses, poor delegation of task poor, management and leadership approach and lack of resources management process in healthcare framework (Catania et al. 2020). All these challenges interfere with the care experiences of patients that raise question on professional accountability and professional integrity of nursing professionals. Recent health survey across the world shows that, majority of the nurse experiences lack of modern clinical equipment such as the oxygen cylinder, ventilation system. COPD management system, pain management and automated screening and monitoring system for illness and health deterioration (Fernandez- Castillo, 2020). All these drawbacks pose adverse impacts on the overall care delivery process to the patient patients. In this context, national and local health care authority need to work with international and national government to get the proper fund and resources that will enable the health care organisations to arrange proper clinical equipment ad machineries that are required for nurses and doctors for arranging immediate clinical support for COVID 19 patients who suffers from sudden heath decline. On the other hand, healthcare authority of all the healthcare organisations needs to emphasize on improving the overall communication and information delivery system that will assists entire healthcare team to maintain transparent and effective communication with all health care professionals and health and social care staffs.

Discussion

From the thematic analysis, it can be seen that in terms of the aim and objectives of this ILR, the following aspects are worthy of discussion…… In this ILR, the nurses’ experience of working on the frontlines during pandemics has been high lightened. Despite, lesson learnt from previous pandemics such as SARS (2003), HINI (2009), MERS (2012), and the advancement in nursing interventions, technology, mode of communication, these measures did not prevent the impact of current pandemic (Covid19) on nurses, which has great impact on their physical, mental and psychological well-being (WHO, 2020). It is significant that none of these pandemics or epidemics were as challenging as the SARS-Cov-2 (Covid19) pandemic, that has stretched all the limits of nurses and health care system all over the world (WHO, 2020; Ulrich, Rushton and Grandy, 2020). Nurses always stand at forefront during any health crises (natural, biological, chemical, radiological) with their new roles, responsibilities and unknown challenges (Harthi et al., 2020). These pandemics, especially current Covid19 pandemic has brought nursing to the forefront in unpredicted way and shown the world nurses’ true ‘heroism’, along with the core values as well as vulnerabilities (Ulrich et al. 2020). In addition to this, it exposed the unpreparedness and inadequacies of the organizations, nursing leaders and government policies (Ulrich, Rushton and Grandy, 2020; Kim, 2018; He et al. 2020; Fernadez-Castillo, 2021) and also, highlighted nurses’ unpreparedness, lack of experience and education and this contributed to their ethical dilemmas and moral distress (Kim, 2018; Galehdar et al. 2020; Moradi et al., 2020). Studies showed that nurses felt that they were unable to provide the quality of optimal care, they morally and professionally obliged to provide (Fernadez-Castillo, 2021). Covid19 pandemic has brought attention to prioritize care, managing resources in more utilitarian way (Morley et al. 2020). However, the result of these studies also highlighted the nurses felt powerless in the management and distribution of human and materialistic resources (Moradi et al, 2020), lack of skills and experiences (Fernadez-Castillo, 2021) further added to their stress and burnout (Corley et al, 2010; Kim, 2018; Moradi et al., 2020; Gralehdar; Arcadi, et al. 2021). It is significant that during Covid19, despite, nurses’ role has been changed in ‘interspersed way’ (Fernandez-Castillo, 2020) however, they felt powerless in decision-making or in authority with doctors in terms of goals of treatment, and with leaders in terms of management of limited resources such as PPE, allocation of staff and faced conflict over goals of care and discrimination over distribution of PPE (Moradi et al, 2020). Similarly, to support this, Fernadez and Moreira (2013) states that nurses do not confused over the right thing for the patient but become morally distress when faced obstacles to do right thing for the patient in emergency. Additionally, nurses has to follow poor choices of senior leaders and find ethical dilemma to challenge them (Rainer, Schneider and Lorenz, 2018). Therefore, there is need of ethical practice environment where nurses given opportunity to raise their voices and these should be heard and respected (Billing et al. 2020). The studies showed lack of preparedness of organizations, government’s disaster management policies and strategies that caused chaos, ineffective responses and care measures (WHO, 2020, Harthi et al. 2020). All studies collectively found that whilst caring of a patient with infectious disease, PPE were considered the most important resource. Fernandez et al., (2020) states that most health professionals are certainly aware of the seriousness of the situation. The studies by Kim, (2018); Catania et al., (2020) showed that inefficiency of organisations regarding effective, clear information about infection control measures and lack of such protective gear and fear of getting infected by deadly virus caused anxiety, chaos and insecurity among nurses (Fernandez- Castillo, 2020).The Consequently, nurses felt ethical pressure, moral distress whilst providing care to their patients in such dangerous environment (Torda, 2006, Corley, 2010; Lam and Hung, 2013; Kim, 2018; Catania et al. 2020). Despite the ethical, moral and professional dilemmas and negative experience of pandemic, most of the studies also showed nurses’ strong essence of professionalism and ‘duty of care’ towards patients and mutual inter-personal co-operation towards their colleagues, which helped them to improve patient outcomes and also, helped them to overcome from their physical exhaustion, fear and anxieties (Schroeder, 2020; Lam and Hung, 2013; Kim 2018; LoGiudic and Bartos, 2021; Arcadi et al., 2021). In all studies nurses’ defined ‘care of patients’ with infectious disease as an ‘essential professional duty’ ( Kim, 2018; Fernandez et al., 2020; Arcadi, et al, 2021 ) and the essence of their duty of care and responsibility emerged as an emotional taint with compassionate fatigue, which was associated with an ethical principle of altruism (Schmidt and McArthur, 2018; Arcadi, et al, 2021).

Strengths of this ILR- This ILR based on qualitative phenomenological studies that helped to capture nurses’ lived experiences during pandemics. The qualitative research is more appropriate to highlight a subjective area such as nurses lived experience and the ethical dilemmas can be truly depicted in the qualitative studies through direct quotes of the participants.The Cormack (2007) critique frame was used to assess methodological qualities of included studies. The validity of this ILR is based on the similar of findings of all studies.

Limitation of this ILR- It is worth noting that most of the studies selected were qualitative studies in this ILR than quantitative. However, lack of quantitative studies shows lack of interventional studies on nurses’ experiences, which is essential for shaping strategies to address challenges faced by nurses at frontline during a pandemic. The lack demographical data limited the larger presence of participants in qualitative studies which is an important element but missing in this ILR. Another limitation of this ILR is that there is not any research included from the UK as there were not many research papers on the topic and matched with the inclusion criteria of this ILR. Many researches on Covid19 started getting published since January 2020. Limited databases were used therefore some papers may have been missed, which may have potential to provide more information on pandemics. Studies searched a limited number of databases as Covid19 related studies is available online and granted for free by Elsevier. Most of the studies included were of average quality as far as transferability of the results are concern.

Lessons we need to carry forward (Implication for future practice) –

In this ILR, the lessons learnt from these pandemics are complex and related with different organizations, government law, policies, societies and nursing leaders. These pandemics especially current Covid19 pandemic has raised awareness of nurses challenges and exposed several implications for future preparedness worldwide.One of the most important aspects found in these studies was that nurses lack power or leadership authority in the management of scarce resources, conflicts and deal with such health crisis. Nurses has potential to support and protect the healthcare system. They should be given power of leadership and need to be involved in decision making and planning for future preparedness. Their voice should be heard and respected. There is need of prioritizing adequate safety measures for nurses worldwide, so that they can work in a safe environment. Organi zations and government must realize their responsibility to minimize nurses’ workload with adequate staffing level. The impact of these pandemics on nurses’ mental health is clearly emerged in all studies, there is need of effective strategies to mitigate negative mental health problems such as buddy system and ethical forum. Also, important for early detection of mental health conditions. Another important factor needs to be consider that nursing leaders, decision makers, governments should provide special education and training for nurses to enhance their knowledge and skills in order to respond confidently, effectively and efficiently to manage any kind of health crisis in future. It is essential that communication should be concise and clear regarding new policies and procedure related to such biological disaster, so that there should be no conflicts and ethical issues between nurses and management. Further, nurses’ family commitments should be acknowledged and nurses should given break from their hectic schedule.

Conclusion

From the above-mentioned discussion, it can be summarized that, nurses must have good skill and abilities in maintaining an effective leadership and management roles in their workplace to provide the high-quality care to COVID 19 patients. During this COVID 19 pandemic, effective management and leadership style need to be implemented into practices by the nursing professionals to manage a perfect balance among the care delivery to the ever-increasing numbers of COVID 19 patients in the hospitals. from overall findings of selected literature, it can be summarized that, in terms of conducting the early detection of and response to the health needs as well as health deterioration of COVID 19 patients, nurses need to use the appropriate leadership styles. Relevant leadership style will assist nurses to follow a systematic process of goal setting, develop heath care strategies for achieving these goals, communicate with health professionals and detect and meet the health needs of COVID 19 patients. Additionally, the effective and relevant leadership approach will enable nursing professional to maintain perfect balance among all their tasks such as observing patients, checking health status of patients on regular provide all the health-related updates of COVID 19 patients to doctors and maintaining effective communication with patient’s family members. Senior registered nurses need to perform an effective leadership role to lead the entire nursing team towards following the systematic process for achieving the common healthcare goals. On the other hand, effective leadership roles of nurses is associated with empowering patients by developing self-management skill in them that can improve their physical and psychological health.