INTRODUCTION:

The COVID-19 epidemic has crossed across the globe in span of months and the World Health Organisation has declared it “Pandemic”. The first known case of COVID-19 was reported on 30 January 2020 in India. Government of India launched measures to curb spreading of this virus. Mainly included steps like cluster containment, Isolation of cases and quarantine of contacts. For all suspected cases had been hospitalized and kept in isolation in designated hospitals till lab testing confirms diagnosis. Hospitalization is extended in isolation wards till two of their samples are tested negative as per MoHFW’s discharge policy. Isolation here refers to separation of individuals who are ill and suspected or confirmed of COVID-19.

In isolation units care is provided tirelessly by nurses round the clock. Many issues have come into limelight being faced by nurses on personal front, administration issues and psychological issues. (1) This article highlights the main concerns faced by nurses working in covid-19 unit setting in a pandemic and some ways to solve those problems.

METHODS AND MATERIALS:

Articles were extracted using keywords like COVID-19, H1NI1, isolation units, patient care, nursing care, problems faced by nurses etc. from PubMed and Google scholar between the March to June 2020. Grey literature was also searched for prevalence and new management strategies.

Obstacles faced by nurses while working in COVID–19 isolation patient care units:

Physical burden:

Nurses have to physically strain themselves round the clock and continuously checking on patient with respiratory assessment. Every patient has to stay in their room, so their activities of daily living are all facilitated by nurses, such as getting food and water. When severely ill patients cannot get out of bed without oxygen, assistance for basic needs like elimination, nutrition, hygiene etc needs has to be maintained. (2)

Risk of infection:

Increased risk of infection for self is a constant disturbing fear among nurses. The risk of transmissibility, pathogenicity and treatment of the disease is still under known. Concerns for family transmission of disease are exhibited by majority of the nurses especially for vulnerable population at home like elderly parents, pregnant wife, immune-compromised near ones and children. Nurses working in Chinese hospitals have reported to be in constant doubt regarding self-infections, panicking if anybody coughs at workplace, in case of minor sore throat self-monitoring temperature multiple times. (3,4)

Emotional burden:

Nurses need to take the burden of supporting emotional and physical needs of Covid-19 patients, as the patient is admitted all alone and would be in isolation area till results are tested negative. Lack previous encounter or experience of working in isolation units could be felt as oppressive and stress full while entering these units. Nurses have reported fluctuating mood with their patient’s condition. Nurses felt happiness and great relief when condition improves but faced low mood and sense of powerlessness on deterioration of patient condition even after putting their best effort. Nurses had to face some depressive situation like seeing whole of family been dead because of Covid-19, when patients load increases the choice of making who to be given lifesaving ventilator support put them in ethical dilemma that too on a daily basis. (5)

Isolation environment:

Structural aspect of an isolation unit could be constant reminder of threat that they are assigned to care for a life risking disease affected patient. The structural aspect included the restricted zoning, disinfection efforts, and isolation measures, single entrance and passage for medical staff for entering Covid-19 areas, working in negative pressure areas brings a sense of oppression making in difficult to breathe. The virus spread with high pace giving less or nil time for designated hospitals to be made. Expecting high causality regular wards that were not initially designed for infectious diseases were modified into isolation wards within a short time. Most of them did not fulfill the criteria of infectious disease units or lacked equipment when they were set up. The layout of the clean, contaminated, and semi-contaminated zones did not fully meet the standards. Initial duration faced scarcity of supplies equipments and too much lending from other working units. Nurses had a tough time being the material manager and being utilizers of these short supply hospital items till time, inventory management could be done with experience of previous day in Covid-19 specific area utilization records. (6)

Manpower issues or lack of trained respiratory nurse practitioner:

Healthcare providers posted in designated Covid-19 units hap-hazardously due to short time, most had no experience of working in an intensive care unit or dealing with critically ill patients requiring mechanical ventilation, so they needed to learn and master new technical procedures in a short time. Nurses had to take orders from physicians who were not specialized in critical care procedures or were specialized in non-clinical areas or less emergency areas like field of psychiatry, dermatology etc. Working with new physician team suddenly made difficult to understand their work pattern or team coordination and collaboration. Prescribing and processing orders tend to be little messy. Nurses would take some time to find new ways to make the whole process as smooth as possible and ensure the quality of care.(1)

Practice guidelines:

Updated information about covid-19 could be encouraging to the nurses. Information need to be concise as lengthy and complex instruction might mess up things in this stressful and mentally demanding time. The guidelines if too complex due to short time and highly demanding situation nurses might mix many communications. Changing guidelines is another area of concern as new studies are coming up every other day. Each member should be communicated any change through electronic media to avoid unnecessary chaos. Due to physical restrains being implemented by government and institution to avoid disease spread circulation of material on infection control through contact less mode of communication including notice board, email, intranet common room, infection control seminar and shift report meeting could be helpful. (3)

Challenges while using protective measures:

Studies shows that Nurses finding challenging job to care Covid-19 patients by wearing PPE (Personal Protective Equipment), Protective googles, face shield, layers of gloves for a long period of time withholding basic physiological need of self. Nurse provides care in terms of Intravenous Catheter insertion, Medication Administration, Vitals monitoring and meeting all needs of patients by wearing extra clothes and following infection control protocols. Nurses reported working in PPE makes difficulty to walk around in unit. The goggles become blurry difficult to see medication names, writing nursing notes, the face shield becomes hazy. Even if PPEs and other safety measures add a layer of protection, the challenge of working long shifts, sometimes lasting even 10-12 hours each, decreases stamina, lead to fatigue and undue exhaustion. (3)

Issue of sexual assault:

Nurses working in isolation Covid-19 units were unfortunately made to face some untoward incidents of sexual harassment. Being in hazmat suit makes it difficult to identify the other person. Many a times whole isolation unit might be having a few or single patient or opposite gender colleagues. Security could be an issue and whole area might be sealed and guards might be posted outside the unit corridor. Some untoward incidents were alleged by nurses against some administrators of a north Indian hospital. (7) Patient’s quarantined at Covid-19 units have allegedly misbehaved with the nurses, making lewd remarks and indecent stripping, provoking the state government’s decision to invoke the stringent National Security Act against them. (8)

Interventions to address obstacles faced by nurses working in COVID -19 unit

1. Provide intense education and training for nurses:

Adequate education and training content includes the use of personal protective equipment (PPE), hand hygiene, ward disinfection, medical waste management, and sterilization of patient-care devices and management of occupational exposure. (9)

2. Reasonable shift schedule:

An alternating shift system can be done for periods of rest and ensure that there are rotation of workers in high-pressure roles. A six hour shift with one hour overlapping has been found to be accepted by 74 % of the nurses working in isolation units. An eight hour divided shift (4 hour morning- 4 hour evening) in day meant putting PPE kit twice which increased consumption of PPE kit and frequent movement between contaminated and clean area increases chances of infection, and frequent donning and doffing off procedures increased their mental burden. Whereas a six long hour shift was putting pressure to control their physiological needs and increased fatigue. Whereas six hour shift with one hour overlapping helped nurses to give handover comfortably and they help fellow nurses in complicated procedures.(10)

3. Duty Roster rotation plan:

Nurses divided into three groups for working in isolation units: one group on duty, second on quarantine/standby and third one being reserve depending upon surge capacity of institution. A two weekly rotation could be practiced among the groups. Non clinical staff or from nursing college could be involved in activities like training, triage, communications, data management, logistics etc.(11)

4. Third party donning doffing observation:

Nurses tend to mix up steps of donning and have higher contamination risks while doffing. (12) A third party observer either an infection control nurse or someone from team could remind the nurse while wearing and taking out PPE. Either a checklist could be filed by standing near the nurse to be posted or a room with observation cameras or instruction with an audio aid could be given. In previous studies this has helped in avoiding post exposure two weeks quarantine. (10)

5. Minimizing cross infection:

Avoidance of unnecessary contact could be fruitful in infection prevention. Use of hospital information system for patient condition reporting could minimize contact. This includes use of digital patient records including doctor’s order sheet, medical records, consent forms, patient information sheets, examination notes and nursing notes. Enough supply of digital materials like infrared thermometer, robotic medication and food delivering trolley, computers, internet connection, in camera observation could minimise nurse patient contact and reduce chances of cross contamination. Use of email or online platform for reporting to administration and physician by nurses would further help.¹⁰(10)

6. Accommodation facility:

Providing access to on-call rooms for nurses who are working long shifts. Accommodation facilities can be made available, to allow nurses to temporarily isolate themselves from their family and reduce concerns around transmitting the virus. Supplies of basic provisions such as snacks, water, phone chargers and toiletries for nurses. Designated break times for nurses. (12)

7. Special consideration:

As per government policies SOP to be formed for vulnerable population among nurses like with chronic ailments, immune-compromised conditions, pregnancy or respiratory diseases to be assigned to less infective area or in nursing administration and training activities. (13)

8. Self-engagement:

Nurses can be encouraged to create a video record of their daily routine; this could be shared with concerned family members to provide some reassurance. Leisure activities can be coordinated to promote relaxation when not at work. Daily communication through telephone could be relieving for nurse and their near ones. (14)

9. Provide psychological counselling:

Prepare Nurses for actual job and associated challenges before posting in isolation units, avoiding false reassurances and actual information about upcoming job responsibilities could reduce anxiety. Providing reflection tool to discuss emotional and social challenges, to create a normalising culture for disclosures of vulnerability. Regular team meetings to boost morale. Posting junior nurses with limited experience with senior staff. Debriefing session after any unfortunate incident like death. Use of coping strategies such as sufficient rest and healthy food, engage in physical activity, and stay in contact with family and friends including through digital methods. Provision of adequate information on stress management, identification of burnout and available support services for registered nurses. (15) Providing adequate security, sexual harassment committee for nurses working in isolation units. Country like India has developed its own self- assessment risk application (Arogya Setu) for Covid-19Use of Mindful Ethical Practice Resilience and Moral Resilience Rounds, a virtual gathering of nurses working in different hospital units and sharing ethical challenges being faced has been found to be useful. (16)

CONCLUSION:

Hospital-related transmission of the virus is still a threat to nurses who are at the front lines of care and are thus more susceptible to infection. Nurses are scared for their co-workers, families, friends, communities and country. Despite this fear, they continue to fight on the frontlines to execute their job. Issues faced by nurses while working in isolation need more attention from the administrative team of the institution. More allocation of hospital resources for betting working condition for nurses including enhanced safety measures to be implemented. More training and opportunity for seeking psychological help need to be arranged on priority basis. To overcome scarcity of nurses as manpower prevention of nurses from getting infected is the need of the hour.

Table: 1 Psychological support helplines for nurses during COVID-19 in India:

S. No	Organization	Services
1.	NIMHANS (17)	Psychosocial support and mental health services during disasters. 24 x 7 toll free helpline. Toll-free number - 080 – 4611 0007
2	Ministry of health and family welfare (18)	Toll-free helpline-0804611007
3	Ziqitza healthcare Ltd under Ministry of health and family welfare (19)	COIVID helpline-104
4	Indian medical association (20)	Helpline number for nurses -+91-9999116375 and 9999116376
5	Mastermind Foundation or The Mind Care App (21)	“Pan India Free Counselling Service” to the citizen of India in 11 languages.

REFERENCE:

1. COVID -19 Outbreak, Guidelines for Setting up Isolation Facility/Ward. National Centre for Disease Control [Internet]. Available from: https://ncdc.gov.in/WriteReadData/l892s/ 42417646181584529159.pdf

2. Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, Xia L, Liu Z, Yang J, Yang BX. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet Global Health. 2020 Apr 29.

3. Godderis L, Boone A, Bakusic J. COVID-19: a new work-related disease threatening healthcare workers. Occupational Medicine (Oxford, England). 2020 May 2.

4. Ehrlich H, McKenney M, Elkbuli A. Protecting our healthcare workers during the COVID-19 pandemic. The American Journal of Emergency Medicine. 2020 Apr 17.

5. Sun N, Shi S, Jiao D, Song R, Ma L, Wang H, Wang C, Wang Z, You Y, Liu S, Wang H. A qualitative study on the psychological experience of caregivers of COVID-19 patients. American Journal of Infection Control. 2020 Apr 8.

6. Chen X, Tian J, Li G, Li G. Initiation of a new infection control system for the COVID-19 outbreak. The Lancet. Infectious Diseases. 2020 Apr;20(4):397.

7. Jafri A A. medical staff, nurses in lucknow’s balrampur hospital demand 14 day quarantine [Internet]. 2020 Apr 09 [cited on 18 May 2020]. Available from: https://www.newsclick.in/medical-staff-nurses-lucknows-balrampur-hospital-demand-14-day-quarantine

8. NSA slapped against quarantined Tablighi Jamaat members who harassed nurses in Ghaziabad [Internet]. 2020April03[cited on 29 may 2020]. Available from: https://theprint.in/india/nsa-slapped-against-quarantined-tablighi-jamaat-members-who-harassed-nurses-in-ghaziabad/394708/

9. Chen X, Tian J, Li G, Li G. Initiation of a new infection control system for the COVID-19 outbreak. Lancet Infect Dis. 2020. PMID: 32085850. https://doi.org/10.1016/S1473-3099(20)30110-9. [Epub ahead of print].

10. Huang L, Lin G, Tang L, Yu L, Zhou Z. Special attention to nurses’ protection during the COVID-19 epidemic. 2020. 1-3

11. Reference Guide for Converting Hospitals into Dedicated COVID Hospitals [Internet]. [cited on 30 May 2020.Available from: https://dhs.kerala.gov.in/wp-content/uploads/2020/03/How-to-convert-Hospital-into-COVID-Hospital.final-pdf

12. Suen LK, Guo YP, Tong DW, Leung PH, Lung D, Ng MS, Lai TK, Lo KY, Au-Yeung CH, Yu W. Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission. Antimicrobial Resistance & Infection Control. 2018 Dec 1;7(1):157.

13. Government of India Ministry of Home Affairs [Internet].[cited on 14 May 2020].Available from: https://www.mha.gov.in/sites/ default/files/MHAOrderextension_1752020_0.pdf

14. Selikowitz A. Mental health challenges for healthcare workers during the COVID-19 pandemic – Impact and management strategies [Internet]. [cited on 23 May 2020]. Available from: https://psychscenehub.com/psychinsights/mental-health-challenges-healthcare-workers-during-covid-19-pandemic-management-strategies/

15. Guidance for General Medical and Specialised Mental Health Care Settings [Internet]. NIMHANS. [cited on 09Jun2020]. Available from:https://nimhans.ac.in/wp-content/uploads/2020/04/Mental Health Issues COVID-19NIMHANS.pdf

16. Katie Pearce. In fight against covid-19, nurses face high-stakes decisions, moral distress [Internet]. [cited on 06 Jun2020]. Available from: https://hub.jhu.edu/2020/04/06/covid-nursing-cynda-rushton-qa/

17. Psychosocial support and mental health services helpline [Internet]. [cited on 04Jun2020]. Available from: http://nimhans.ac.in/pssmhs-helpline/

18. Measures undertaken to ensure safety of health workers drafted for COVID-19 services. Ministry of health and family welfare. [Internet]. [cited on 06 Jun2020]. Available from: https://www.mohfw.gov.in/pdf/MeasuresUndertakenToEnsureSafetyOfHealthWorkersDraftedForCOVID19Services.pdf

19. Dial 104 – National Helpline dedicated for COVID 19 [Internet]. [cited on 06 Jun2020]. Available from: https://ehealth. eletsonline.com/2020/03/dial-104-national-helpline-dedicated-for-covid-19/

20. Yash Ved, Mumbai, Tuesday, April 14, 2020, 08:00 Hrs [IST]. IMA launches psycho-social counseling helpline for doctors and healthcare workers for COVID-19 treatment [Internet]. [cited on 06 Jun2020]. Available from: http://www.pharmabiz.com/News Details.aspx?aid=122421&sid=1

21. Covid 19 – free counseling – pan india [Internet]. [cited on 08 Jun2020]. Available from: http://www.mastermindfoundation. com/

Received on 22.06.2020 Modified on 04.08.2020

Asian J. Nursing Education and Research. 2020; 10(4):459-462.

DOI: 10.5958/2349-2996.2020.00098.1