key: cord-318701-f9j13fsc
authors: Chamboredon, P.; Roman, C.; Colson, S.
title: COVID‐19 pandemic in France: health emergency experiences from the field
date: 2020-06-22
journal: Int Nurs Rev
DOI: 10.1111/inr.12604
sha: 
doc_id: 318701
cord_uid: f9j13fsc

AIM: This paper describes the situation regarding COVID‐19 emergency in France as of early May 2020, the main policies to fight this virus, and the roles and responsibilities of nurses regarding their work at this time, as well as the challenges facing the profession. BACKGROUND: Europe continues to be affected by the COVID‐19 pandemic. At the time of writing France was the fourth country with the highest number of detected cases and cumulative deaths. SOURCES OF EVIDENCE: Websites of the World Health Organization, French Government, French Agency of Public Health, French National Council of Nurses and ClinicalTrials.gov database, as well as the experiences of the authors. DISCUSSION: The history of the development of the pandemic in France helps explain the establishment of the state of health emergency and containment of the population. Many decisions made had undesirable repercussions, particularly in terms of intra‐family violence, mental health disorders and the renunciation of care. Hospitals and primary care services, with significant investment by nurses, played a key role in the care of persons with and without COVID‐19. CONCLUSION: France has suffered a very high toll in terms of COVID‐19 morbidity and mortality, and effects on its people, health systems and health professionals, including nurses. IMPLICATIONS FOR NURSING PRACTICE: Nurses are recognized for their social usefulness in France. However, it is important to consider the collateral effects of this crisis on nurses and nursing and to integrate the health emergency nursing skills established during the pandemic into the standard field of nursing competence. IMPLICATIONS FOR NURSING POLICY: The nursing profession has expectations of a reflection on and revision of nursing skills as well as of its valorization in the French healthcare system, notably carried out by the French National Council Order of Nurses.

• Present a brief history of the development of the pandemic in the country, including the political decisions that have been taken to combat it; • Explain the repercussions of containment measures on the health of the population;

• Describe the roles and responsibilities of nurses regarding their work during the pandemic, as well as the challenges facing the profession; and • Summarize the current French research studies in progress about COVID-19.

The COVID-19 pandemic is undoubtedly the most serious global health crisis in decades, causing more than 283 000 deaths worldwide as of 12 May 2020 (World Health Organization [WHO] 2020a). This is a devastating new virus. First reported in Wuhan, China, on 31 December 2019, the virus gradually spread to Europe and the rest of the world (WHO 2020b). The emergency situation was declared by WHO on 31 January 2020. Within 100 days of the outbreak of the virus, the Director-General of WHO found that more than 1.3 million people were confirmed as infected, of whom nearly 80 000 died (WHO 2020c) .

At the time of writing on 12 May 2020, the situation in Europe remains catastrophic: more than 1 750 000 reported cases and more than 157 000 cumulative deaths (WHO 2020d) . The most affected countries are Spain (227 436 detected cases, 26 744 cumulative deaths), the United Kingdom (223 060 detected cases, 32 065 cumulative deaths), Italy (219 814 detected cases, 30 739 cumulative deaths), Germany (170 508 detected cases, 7533 cumulative deaths) and France (139 519 detected cases, 26 643 cumulative deaths). The situation has necessitated the reorganization of healthcare systems and changes in population lifestyles and has led to particularly difficult economic consequences.

To date, the primary strategy has been to utilize cross-contamination measures to prevent the spread of the virus such as good hand hygiene, avoiding close contact with others or social distancing and respecting respiratory hygiene rules. Population containment measures have been implemented in many countries, and particularly in France, from 16 March 2020. France is the fourth most affected country in Europe. The number of deaths is important, but just as important are the more than 57 000 people who underwent hospitalization for COVID-19 (French Public Health 2020) . The data are updated daily. The most reliable indicator to date remains the incidence of COVID-19 cases entering resuscitation/critical care every day, which is beginning to plateau. France must manage the first wave of the pandemic while deploying all means to avoid a second wave. Health policies must then adapt to a virus whose spread is not fully known and whose treatments are currently being evaluated. These many unknowns in the equation lead to the need to adjust policy measures in France on an almost daily basis.

In preparing this report from the field, relevant information was taken from the websites of WHO, French Government, French Agency of Public Health and French National Council of Nurses. The ClinicalTrials.gov database was also examined. We have also drawn on our experiences as French nurses.

The identification of the first three cases of COVID-19 positive patients was announced by the Ministry of Solidarity & Health (2020a) on 24 January 2020. The virus began to circulate in France, considered to have been transmitted by people who had stayed in China or Singapore and had been in contact with infected people. The first death in France was announced on 15 February 2020 (Ministry of Solidarity & Health 2020b). Despite the isolation of the cases identified and the reminder to the public to practice barrier actions, COVID-19 spread. Subsequently, the Minister of Solidarity and Health, Olivier V eran, initiated the Plan d'Organisation de la R eponse du syst eme de sant e en situations Sanitaires exceptionnelles (ORSAN) (Organizational Plan for Health System Response in Exceptional Health Situations) under the epidemic and biological risk section on 23 February 2020, enacting the various protocols to be implemented in the context of a health crisis (Ministry of Social Affairs, Health and Women's Rights 2014). Stage 1 of this plan consisted of isolating the identified cases and the people they had been in contact with, at the time numbering about 40 people, to slow down the spread of the virus in the country. A few days later, on 29 February 2020, France moved to Stage 2, which consisted of slowing down the viral spread, following the identification of several epidemic outbreaks and the first deaths linked to COVID-19. Barrier measures were widely disseminated to the population, and containment measures were implemented locally in areas with identified infectious outbreaks. On 12 March 2020, when WHO declared the status of a pandemic concerning the novel coronavirus (WHO 2020e), crisis measures were taken by the President of the French Republic (2020a) and his government, to control the epidemic and manage the health situation, namely, the closure of the nurseries, schools and universities for users as of 16 March 2020 ; the introduction of short-time work hours for employees whose companies cannot carry out their activities and of teleworking for all employees who have this possibility of adjusting the exercise of their profession (Ministry of Solidarity & Health 2020c).

However, a few days later, the number of cases and deaths increased. Stage 3 was declared to reduce the circulation of the virus in the population and mitigate its effects. All nonessential public places were closed, and several measures put in place by the French government to manage what was becoming the country's biggest health crisis in several decades. On 16 March 2020, the President of the French Republic spoke live on television, declaring that 'We are at war' against COVID-19 (2020b) .

The White Plan corresponded to the provisions of ORSAN to organize health facilities in response to a major health crisis (Ministry of Social Affairs, Health and Women's Rights 2014). It consisted of four points: mobilizing health establishments to respond to a crisis situation, mobilizing health professionals, mobilizing the material and logistical resources of establishments and adapting their medical activity. Initiated in health establishments close to identified epidemic outbreaks, the White Plan was generalized throughout France when the epidemic reached Stage 3.

A new gradation of care began to be implemented: university and public hospitals as the first line to receive patients with COVID-19, private hospitals with at least an emergency department and critical care service as the second line and private hospitals with critical care service as the third line. All other care facilities were placed in the fourth line. COVID-19 units were set up in more than 150 public hospitals, and new resuscitation places were being created, increasing the capacity from 5000 to 7900 beds (Prime Minister of the French Government 2020). Healthcare professionals were mobilized as well as health students on internships or volunteers, and retired people were also called upon to strengthen healthcare teams. The French system of mobilization by the State of volunteer health professionals in exceptional health circumstances, known as the Health Reserve, was activated to provide support in the areas most affected by the epidemic (Ministry of Solidarity & Health 2020d). Non-urgent medical activities were deprogrammed, and the monitoring of chronic pathologies was reorganized.

Primary care teams, especially home care nurses, were also referred to as backup, to manage not only the usual care of the population but also the aftercare of COVID-19 patients discharged from hospital or those who did not require hospitalization, only simple monitoring at home.

However, as the existing legislative and regulatory measures were not sufficient to deal with the crisis, the French State introduced the State of Health Emergency (President of the French Republic 2020c). This new state of health emergency covered parts or all of the territory (including overseas territories) in the event of a health disaster that, by its nature and severity, endangered the health of the population.

Within this framework, the Prime Minister, as head of the French government, could decree measures listed by the law: order home confinement, requisition personnel and equipment, and prohibit gatherings. The Prime Minister could also take temporary measures to control the prices of certain products, allow patients to have access to medicines and decide on any regulatory limits to entrepreneurial freedom. The Minister responsible for health could, by ministerial order, determine other general and individual measures.

The military operation 'RESILIENCE' was launched on 25 March 2020 (Ministry of The Army 2020). The French army served as a reinforcement to provide assistance and support to the population and public services in terms of health, logistics and protection of the entire territory. Mistral and Dixmude helicopter carriers were deployed in the southern Indian Ocean (Reunion, Mayotte) and in the Antilles-Guyana regions.

Implementation of containment throughout France up to 11 May 2020

To decelerate the circulation of the virus, the government implemented a containment of the French population (Prime Minister of the French Government 2020b). Travel was severely restricted. A certificate justifying individual movements was required to leave the home, and checks were carried out by the police and the army to ensure that these restrictions were respected by the population. Those not respecting the confinement were fined or even sentenced to imprisonment according to the severity of the situation.

Economic measures were put in place urgently by the French state (President of the French Republic 2020c). To safeguard jobs and reduce the risks of job insecurity, a shorttime working scheme was launched for the duration of the confinement, enabling more than 10 million people to receive at least three-quarters of their wages. An adapted sick leave scheme was set up for parents of children under 16 years old who could not telework, pregnant women in the third trimester, and vulnerable or fragile persons. Unemployment benefit entitlements were extended for persons reaching the end of their entitlement. Several types of aid were likewise offered to companies affected by the crisis, to safeguard them and secure jobs in France.

Concerning children's schooling, pedagogical continuity was achieved at a distance, in virtual classes, or through homework assignments to be carried out with the help of parents. This system had major limitations, including the absence of computer equipment in low-income families, saturation of the bandwidth of internet connections and saturation of educational platforms, which are not accustomed to such a large number of simultaneous connections.

Containment measures were applied in medical establishment for dependent older adults for dependent older adults (EHPADs), where the circulation of the virus was particularly harmful. Older adults were initially confined to their rooms, without visiting rights, and these measures were recently relaxed, with permission for visits without physical contact.

The French government conferred a broadening of competences and recognition of the role of home care nurses. The health context made it possible to create the first telecare procedure related to the management of patients with COVID-19 by home nurses during the period of the state of health emergency (High Authority of Health 2020; Prime Minister of the French Government 2020c). For the duration of the epidemic, a patient diagnosed with COVID-19 could benefit from telecare on prescription, as long as the patient guarantees their availability and mastery of the tele-monitoring tools (smartphone, computer with Wi-Fi connection, or, failing that, telephone). Telecare would be fully covered by the French Health Insurance. Before any care was provided to the patient with COVID-19, a nurse collected general information and the care plan prescribed by the doctor for the patient (e.g. points of vigilance, monitoring rhythm). During the first contact, the nurse assessed the patient to confirm the criteria for inclusion in the telecare system, supplemented by measures related to the current situation and, in particular, the implementation of hygiene and prevention measures for the family caregiver. Then, as part of the follow-up set-up according to the severity of the patient's condition as indicated by the doctor, the nurse carried out the following: determining the patient's general condition, looking for signs of worsening symptoms, collecting clinical observations at a distance (e.g. temperature, weight), looking for signs of altered consciousness, looking for signs of dehydration, reminding the family and friends of the hygiene and prevention instructions, coordinating with the doctor regarding an alert without delay if the patient's condition required it, or call for emergency medical assistance in case of distress, in parallel with the information from the doctor.

If the nurses considered that the conditions would no longer enable them to carry out the follow-up, they would then go to the patient's home to carry out face-to-face monitoring and inform the attending physician, who will adjust the prescription for nursing follow-up as necessary. This new system, requested by the Order of Nurses, made it possible to monitor patients while drastically reducing exposure to the risk of contamination for caregivers.

If telecare was not possible for patient follow-up, and to avoid the risk of spreading the coronavirus within home nursing structures, nurses could opt to follow-up their patients at home, even without specific instruction from the medical prescription. The related procedures were subject to specific coverage and price re-evaluation by the health insurance.

Prolonged containment can have several implications for the health of the population. The first concern to be feared was the impact on mental health, brought by social isolation, fear of illness and uncertainties in relation to the illness. A survey was conducted by Sant e Publique France with a sample of 2000 internet users to characterize the impact of COVID-19 on the general population and to influence the political measures to be implemented to care for the population (French Public Health 2020b). Because the abovementioned repercussions may be more severe for people with disabilities, particularly psychiatric disorders, specific measures were recommended by the High Council of Public Health (2020a) to adapt containment measures to the problems of each person concerned. These containment measures were applied in EHPADs, where the circulation of the virus was particularly harmful.

The second concern was that a large, difficult-to-measure proportion of the French population seemed to have given upon their usual, acute or chronic care, mainly because of COVID-19 containment measures and the fear of being contaminated. According to a recent survey by a telemedicine platform, the number of consultations with general practitioners decreased by 44% since the beginning of containment, and by 70% for specialist physicians (Doctolib 2020) . To date, the effects of this situation remain difficult to assess, especially for people with particular health vulnerabilities. Meanwhile, paediatricians alerted the authorities to the decrease in the number of families requesting paediatric consultations, particularly for consultations in connection with the programming of children's vaccinations (French Association of Outpatient Pediatricians 2020). The risk of a resurgence of infectious diseases in children is becoming significant because it is not possible to identify the proportion of children who are not vaccinated according to the vaccination schedule issued by the High Council of Public Health. Third, confinement unfortunately endangers a certain number of women and children who are victims of domestic violence (Usher et al. 2020) . The French government (2020) widely publicized the possibility of contacting a telephone hotline to report situations of violence. Recently, these reports have doubled; however, it is difficult to obtain reliable data to date to estimate the number of collateral victims in confinement. For these reasons, the government has wished to introduce deconfinement for children, who seem less sensitive to the virus, so that a certain number of them can return to school, eat at least one balanced meal a day and escape intrafamily contexts that are harmful to them.

Finally, several French nurses faced threats or were subjected to malicious acts, often anonymous, by neighbours in particular: posters or anonymous letters asking the nurse to move to avoid contaminating an entire residence, vandalism on personal vehicles or in professional premises, theft of equipment and assault. The French National Council Order of Nurses (2020a) assisted nurses who were victims of these malicious acts in legal proceedings.

Gradual deconfinement was being implemented as of 11 May 2020 (Prime Minister of the French Government 2020d). The national deconfinement strategy was based on three main principles: protecting the population through barrier gestures and the wearing of masks in certain situations, testing the population on a large scale and isolating sick people and contact cases. Departmental (territorial division in France) maps were established to report on situations that may or may not be conducive to deconfinement, according to three main indicators: the rate of new cases in the population over seven days, hospital resuscitation capacity, and organization of the local testing and contact case detection system. The deconfinement plan announced the opening of some public places, including schools, but advised the maintenance of teleworking as much as possible. New rules for social life were also introduced. If the indicators were unfavourable, then a department would not be deconfined. Two phases were planned: a first period of deconfinement from 11 May to 2 June 2020, followed by a second period before the summer holidays.

Despite the exceptional purchasing and requisitioning measures by the French government of personal protective equipment (PPE) and other urgent health supplies, caregivers were left with a real lack of protection, as was the case elsewhere in the world. France was counting on its main supplier, China, without foreseeing that if China itself was exposed to a health crisis such as COVID-19, stocks of Chinese products would then be used primarily by China.

To obtain more precise information on the situation, the French National Council Order of Nurses (2020b) carried out an online consultation from 4 April to 7 April 2020, in which more than 70 000 nurses participated (a sample of 10% of the French nursing population). The main results were as follows: • Nearly three-quarters of the nurses consulted stated that they did not have enough PPE. • Of the nurses consulted, 83% said they did not have enough gowns, and 78% said they did not have enough masks.

• Of the nurses consulted, more than two-thirds (65%) stated that they did not have enough protective goggles. • More than half (58%) said they did not have enough overshoes. • More than half (54%) stated that they did not have enough mob caps. • Nearly half (47%) stated that they did not have a sufficient quantity of hand sanitizers.

The French State set up an emergency system for the purchase of PPE. It has been able to count on the solidarity of the French population and companies, which, on a voluntary basis, have developed the production of masks, gowns and hand sanitizers, although this was not their primary function.

To date, 178 French studies on COVID-19 have been referenced in Clinical Trials, 108 of which are in the process of gathering participants. These studies cover the epidemiology of COVID-19, clinical trials of drug treatments and their side effects, and the effects of containment.

Different drug strategies are being investigated, and the results of these studies are expected to be published soon. The results of these studies are eagerly awaited by the French government, by the scientific community, as well as the population.

France has suffered a very high toll in terms of COVID-19 morbidity and mortality, and adverse effects on its people, economy, health systems and health professionals, including nurses. The context of the health crisis caused by COVID-19 in France is leading to strategic and political changes on a daily basis. Health professionals in hospitals and primary care facilities are in the front line of the health management of the crisis. However, the population, through political decisions, has a duty to support healthcare workers to reduce the circulation of the virus. After a confinement of almost two months, France is preparing to live a new life, partly deconfined, but with new habits to implement, and above all, a deep reflection on the aftermath of the pandemic.

Nurses play a key role in the context of the COVID-19 health crisis, in hospitals, medical and social care institutions and primary care. The public is largely grateful for nurses' involvement and dedication in this context. Although public gratitude may bring satisfaction and value to the profession, the collateral effects of this crisis on the nurses themselves need to be studied. The authorities likewise need to ensure that nurses remain in their profession. Derogating measures that would extend the scope of nursing activities during crises also need to be considered to develop and establish them on a permanent basis in nursing practice. It would be inappropriate to withdraw recognized skills acquired during the crisis once the crisis is over.

The French concerns are completely in line with the global concerns raised by the International Council of Nurses (ICN), which calls for the recognition, respect and protection of nurses (International Council of Nurses 2020a).

The context of this health crisis places the nursing profession in a social mandate recognized by the French population. It is imperative that nursing practice be adapted and evolved so that France can win the fight against this virus. The French National Council Order of Nurses (2020c) has asked the French government to deploy several means to help nurses accomplish their daily mission: an intensification of efforts to equip nurses working in residential institutions for dependent older people, medico-social establishments or at home with PPE and systematic screening of health personnel; additional efforts to promote tele-nursing; the introduction of differentiated spaces and rounds of home visits (COVID-19/non-COVID-19); a more efficient system to ensure the quality and continuity of care for all, particularly for at-risk populations and those suffering from chronic pathologies; a strong fight against any malicious act or discrimination towards healthcare workers with regard to their employment and the COVID-19 risk; the possibility for nurses to carry out the entire procedure relating to releasing death certificates instead of a doctor; and the prescription of COVID-19 tests. The French National Council Order of Nurses has also called for an accurate count of nurses infected with and died from COVID-19, the recognition of occupational disease for infected caregivers, and the granting of the status of ward of the nation for the children of deceased nurses. These latter concerns appear to be global, as the ICN also notes that the number of nurses who died from COVID-19 appears to be underestimated (International Council of Nurses 2020b).

These requests were made during the time of the COVID-19 crisis, but the French National Council Order of Nurses asked the French government to rethink completely its vision of the nursing profession. Today, the nurse is an essential link in the patient's care journey. The nurse is a clinician, and this must be reflected in a progressive evolution of nursing skills to include skills regarding medical prescription.

The International Council of Nurses has positioned itself to ensure that the critical role of nurses in the management of COVID-19, as well as in day-to-day operations, is fully recognized by governments around the world (International Council of Nurses 2020c). The State of the World's Nursing report provides a basis for reflection on the evolution of the nursing practice and better recognition of nurses in all countries (WHO 2020f).

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The Order assists nurses who are victims of pressure or aggression in their legal proceedings (in French)

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Address to French population

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adopting adapted conditions for the receipt of cash benefits for persons exposed to coronavirus (in French). Regulatory text 19 March

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WHO Director-General's opening remarks at the media briefing on COVID-19

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Firstly, we thank all nurses in France, from all sectors of activity, for their involvement in this COVID-19 crisis. Secondly, we thank the French National Council Order of Nurses for the financial support for the linguistic revision of this article.

Manuscript design: SC Data collection: PC, CR, SC Manuscript writing: PC, CR, SC Critical intellectual revisions of manuscript: PC, CR, SC