key: cord-290140-mmbzxz06 authors: Lord, Heidi; Loveday, Clare; Moxham, Lorna; Fernandez, Ritin title: Effective communication is key to ICU nurses willingness to provide nursing care amidst the COVID-19 pandemic date: 2020-10-01 journal: Intensive Crit Care Nurs DOI: 10.1016/j.iccn.2020.102946 sha: doc_id: 290140 cord_uid: mmbzxz06 BACKGROUND: The COVID-19 pandemic posed and continues to pose challenges for health care systems globally, particularly to Intensive Care Units (ICU). At the forefront of the ICU are highly trained nurses with a professional obligation to care for patients with COVID-19 despite the potential to become infected. The aim of this study was to explore ICU nurses’ willingness to care during the COVID-19 pandemic. METHODS: A prospective cross-sectional study to explore ICU nurses’ willingness to provide care during the COVID-19 pandemic was undertaken between 25 March to 3 April 2020 at a large principal and referral teaching hospital in Sydney, NSW Australia. RESULTS: A total of 83 ICU nurses completed the survey. Approximately 60% reported receiving sufficient information from managers regarding COVID-19 and about caring for a patient with COVID-19. Ninety percent of nurses were concerned about spreading COVID-19 to their family. Sixty one percent of the nurses indicated that they were willing to care for patients with COVID-19. Receiving timely communication from managers was the only predictor of willingness to care among ICU nurses. CONCLUSIONS: Effective communication is a vital component during a public health emergency in order to promote nurses’ willingness to care for patients in the ICU. causing a severe pneumonia like illness (Gong et al., 2020; Zhou et al., 2020) . Rapidly spreading globally, by early March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. By 8 April 2020, COVID-19 had infected 1.28 million people and caused 72,774 deaths (WHO, 2020) . The COVID-19 pandemic posed and continues to pose C immense challenges for health care systems, particularly to intensive care services. The burden of COVID-19 on health care resources of affected patients in countries other than Australia indicates that approximately 5-16% of confirmed COVID-19 cases required admission to intensive care units (ICU) Grasseli et al., 2020) . This is predominately due to COVID-19 related shortness of breath resulting in hypoxemic respiratory failure requiring mechanical ventilation (Bhatraju et al., 2020) . Following the first reported COVID-19 case in Australia on 25 January 2020 (Liebig et al., 2020) , transmission continued, with strict public health measures implemented in March 2020. ICU services however, outside of Australia were struggling to deal with a surge in critically ill COVID-19 cases (Liew et al., 2020) . ICU nurses in Australia were acutely aware of international trends and thus had to be prepared to respond to this potential situation nationally. Being at the forefront of the ICU and having the most amount of close patient contact, nurses have a professional obligation to respond to the COVID-19 pandemic through delivering health care to critically ill infected patients (Liew et al., 2020; Seale et al., 2009) . A nurse's willingness to provide nursing care during a pandemic can be influenced by their own perceptions of risk of exposure to COVID-19, but also fear for their family's health (Corley et al., 2010) . This perception of risk cannot be underestimated as in some instances, nurses have experienced post-traumatic stress disorder (PTSD) as a direct consequence of working during a pandemic (Corley et al., 2010; Ives et al., 2009) . Previous research Fernandez et al., 2020; Koh et al., 2005; Liu & Liehr, 2009 ) on the psychological distress and wellbeing of health care workers during a pandemic, have indicated that many health care workers exhibit high levels of psychological stress, have concerns about stigmatization and internalize fear associated with their own personal health and their family's wellbeing and health. Nurses' anxiety, concerns and psychological distress in previous pandemic responses have been substantially associated with social isolation, physical and emotional exhaustion, increased job stress, media scrutiny and rapidly changing information and communication (Liu & Liehr, 2009; Maunder, 2004) . Psychological distress can likely cause both short and long term effects on the nursing workforce (Liu & Liehr, 2009 ) of which there is already a shortage. Gaining an understanding of their motivations and willingness to engage in their professional duty of providing nursing care in the midst of extreme challenges can inform future pandemic planning and identify strategies to alleviate psychological distress. To date, there is limited literature on nurses' willingness to provide nursing care during a pandemic; what evidence there is, predominately relates to hypothetical situations. This study explores the willingness of ICU nurses to provide nursing care during the COVID-19 pandemic with the purpose of identifying the response of nursing staff to the pandemic and implementing support services to assist current and future pandemic response. This prospective cross-sectional study design to explore ICU nurses' willingness to provide nursing care during the COVID-19 pandemic was undertaken at a large principal and referral teaching hospital in Sydney, NSW Australia. All registered nurses, including nurse educators and Nurse Unit Managers (NUMs) who worked in the ICU during the study period (25 March -3 April 2020) were invited to participate in the study. Potential participants were asked to partake in the study via a link to the survey in their work email. Completion and submission of the questionnaire were considered as implied consent. No identifiable information was obtained and participants were informed that their participation was voluntary. Data collection occurred during the study period 25 March to 3 April 2020, capturing the first few weeks under the newly implemented COVID-19 restrictions in Australia. Data were collected using a self-administered questionnaire via a SurveyMonkey link. The questionnaire was investigator developed based on an extensive literature review. The questionnaire was then reviewed and tested for content validity by a panel of experts in ICU and nursing academics. Information collected in the questionnaire included: (1) demographic data (age, gender, employment status, and length of time worked as a registered nurse and in the ICU, (2) willingness to work in ICU during the pandemic (1 item) (3) knowledge about COVID-19 (4 items), (4) communication from managers about COVID-19 (2 items), (5) preparedness of the ICU (2 items) and (6) personal concerns about COVID-19 (1 item). Participants were asked to respond to the questions using a 5-point Likert scale (strongly disagree=0, disagree=1, neither agree nor disagree=2, agree=3, strongly agree=4), with two questions requiring an open-ended response. Ethical approval was obtained from the Hospital's Human Research Ethics Committee (HREC) for this study 2020/ETH00827. Quantitative data were analysed using SPSS version 25. Categorical data was presented as percentages and continuous data as means and standard deviation (SD). T-tests and one-way ANNOVA were used to assess the relationship between willingness to provide nursing care and the demographic variables. Pearson's correlational analysis was used to investigate the relationships between willingness to care and knowledge of the COVID-19 pandemic, communication from managers, preparedness of the ICU and personal concerns. Only scores for knowledge of the COVID-19 pandemic, communication from managers, preparedness of the ICU and personal concerns scores were included in a standard multiple linear regression analysis to determine the predictors of willingness to provide nursing care. The Beta (B) values and the 95% confidence intervals were calculated in the multiple regression analyses. Statistical significance was set at p less than 0.05. Qualitative data consisted of responses to open-ended questions. Data analysis was undertaken using a qualitative thematic analysis conducted by two authors independently. The qualitative data was used to gain a deeper insight on the quantitative data. A total of 83 ICU nurses (64 females and 17 males) completed the survey. The overall response rate to the questionnaire was 42% (83/198). Sixty six percent of the respondents were aged below 35 years and the majority (82%) worked full time. A quarter of the nurses (n=20) had worked as a registered nurse for three years or less and half had worked in the ICU for three years or less (Table 1) . Sixty percent of the respondents reported that they had sufficient knowledge of COVID-19 and agreed that they understood how to protect their patients and themselves during the COVID-Willingness to care for patients has been defined as the nurses' intention or wanting to provide nursing care during the pandemic. The aim of this study was to assess ICU nurses willingness to provide nursing care for a patient with COVID-19 during the first few weeks of the COVID-19 pandemic in Australia. This study is novel as it was conducted immediately following the declaration of the pandemic by the WHO and thus at the height of community distress and fear. Our study demonstrated that 61% of the nurses were willing to provide nursing care for a patient in the ICU during the COVID-19 pandemic. These results are higher than in previous studies (Wong et al., 2010; Etokidem et al., 2012 , Damery et al., 2009 Irvin et al., 2008 ) where willingness to care during a pandemic ranged from 23% (Wong et al., 2010) to 50% (Irvin et al., 2008) . Conversely, a study (Ma et al., 2011) conducted in an ICU in China reported a high (82.3%) willingness to care during the H1N1 influenza pandemic. These results could be due to the fact that the majority (90%) of the staff had received training in caring for a patient with H1N1 prior to the commencement of the study and knowledge training prior to patient care was an independent predictor of willingness to care for patients with H1N1. Notably, there was a vaccine available for H1N1 influenza, which may have increased the ICU staffs' willingness to care as the vaccine could be viewed as a protective mechanism. Results from our study concurs with the previous study (Ma et al., 2011) where ICU nurses with greater knowledge about COVID-19 were more willing to provide nursing care for patients. What is new in our study is that it was conducted in the midst of the pandemic when there was limited knowledge globally about the pathobiology of COVID-19. It is also interesting to note that regardless of their knowledge of the COVID-19 pandemic, their perceptions of the preparedness of the ICU and their personal concerns, the multiple regression analysis identified organizational communication regarding COVID-19 as the only predictor of ICU nurses' willingness to provide nursing care. That is nurses who felt that they received higher level of communication from the organization were more willing to provide nursing care during the pandemic. Our study was conducted in the first few weeks of the COVID-19 pandemic in Australia and the ICU had instantaneously implemented additional communication strategies to update staff with the latest information about COVID-19 in order to allay anxiety and engender confidence in working in the ICU. Such communication included information about the transmission of COVID-19, restrictions required due to the risks associated with COVID-19, use of PPE, availability of education and access to mental health services. The specific communication strategies implemented in the ICU in our study were: The COVID Chronicle, which was a weekly newsletter of updates regarding COVID-19; The COVID-19 FAQ, which was a daily factsheet to answer the many questions staff had, that was emailed to staff and also displayed as a hard copy in the main staff areas; a daily COVID-19 staff huddle to update key staff; and lastly, a face to face question and answer session during in-service time that occurred 3 times a week to capture all ICU staff. The most efficient and effective communication strategy implemented was the daily COVID-19 staff huddle and the COVID-19 FAQs. Our study found that the majority (94%) of ICU nurses reported that they understood the risk of COVID-19 for patients, however just over half of the ICU nurses (60%) felt they had sufficient knowledge regarding COVID-19. In addition, many (77%) agreed that they understood how to protect their patients and themselves from infection during the COVID-19 pandemic. Of note is the high level of reported understanding of the risks of COVID-19 to patients among ICU nurses compared to the lower levels of participants reporting sufficient knowledge for self. Perhaps understanding high level of risks to patients could be associated with ICU nurses obtaining their information from mass media coverage of the effects of the pandemic on patients globally. Furthermore, ICU nurses are often experienced at caring for patients with respiratory complications, which may have contributed to their higher levels of knowledge regarding protecting patients. The lower levels of participants identifying insufficient knowledge for self, could be due to COVID-19 being a novel virus, where global understanding of the pathophysiology of the disease was limited. Nevertheless, our findings are consistent with the results of a study by Ma et al., (2011) undertaken in a Chinese ICU during the H1N1 influenza pandemic which found that less than half the ICU staff reported sufficient knowledge, despite receiving education sessions. Interestingly, the willingness of ICU nurses in our study to provide nursing care during the COVID-19 pandemic had no association with demographic factors. That is, irrespective of age, gender or years of experience, ICU nurses are willing to work during the pandemic. These results are similar to another study (Ma et al., 2011) that demonstrated no difference between willingness to care and demographic variables. These studies emphasis that ICU nurses need to feel protected in order to perform their duties regardless of their age, gender or years of experience. A sense of confidence in their skills, knowledge, safety and risk perceptions have been identified in a systematic review (Aoyagi et al., 2015) as enablers for health care workers willingness to care during the pandemic. Our study identified that the majority (90%) of the nurses were concerned about spreading COVID-19 to their family, which could have an effect on their willingness to care. Providing nurses with adequate information and resources on how to protect themselves may assist with alleviating any fears associated with transmission of COVID-19 to family members. Concerns for personal and family safety was a synthesized finding from a systematic review undertaken by Fernandez et al., (2020) who examined nurses' experiences of working in acute care hospital settings during a respiratory pandemic. Therefore, it is vital that pandemic preparedness planning include comprehensive communication strategy for ICU staff, which in turn can reduce factors that cause hesitation and increase factors that cause motivation for willingness to provide nursing care during a pandemic. The ICU in our study was proactive and instituted early strategic communications activities based on scientifically derived risk communications principles. This provided adequate and essential communication which enabled the ICU nurses to improve their knowledge about caring for a patient the COVID-19 pandemic. It also facilitated being able to make the best possible decisions within short time frames in order to reduce the impact of COVID-19 on mortality and morbidity. Like all studies, our study has several limitations that require acknowledgement. Firstly, there is the potential for selection bias due to only 83 ICU nurses who responded to the survey. Additionally, our study was conducted in a single centre. Conducting a multicentre study would have provided more robust evidence. While the findings of the single centre study may be relevant to and resonate with other centres, the results are not generalisable to all ICUs. A further limitation of this study was that it did not assess previous experience or training in pandemic or emergency preparedness response. Further studies will need to assess these. This study highlights that ICU nurses' willingness to care is associated with receiving adequate and timely communication from managers. Once again, highlighting the importance of staff management relationships. It is imperative that nurses working in ICUs during a pandemic have all the information they need to rapidly and accurately provide high standards of nursing care. Enabling a rapid response in a pandemic situation has the potential to significantly save lives. Nil funding. Nil conflict of interest. Healthcare workers' willingness to work during an influenza pandemic: a systematic review and meta-analysis Covid-19 in critically ill patients in the Seattle region-case series The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study Will the NHS continue to function in an influenza pandemic? A survey of healthcare workers in the West Midlands Influenza A H1NI (Pandemic 2009): How prepared are healthcare providers in Calabar Implications for COVID-19: a systematic review of nurses' experiences of working in acute care hospital settings during a respiratory pandemic China's local governments are combating COVID-19 with unprecedented responses-from a Wenzhou governance perspective Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response Clinical characteristics of coronavirus disease 2019 in China Survey of hospital healthcare personnel response during a potential avian influenza pandemic: will they come to work Healthcare workers' attitudes to working during pandemic influenza: a qualitative study Risk Perception and Impact of Severe Acute Respiratory Syndrome (SARS) on Work and Personal Lives of Healthcare Workers in Singapore What Can We Learn The current state of COVID-19 in Australia: importation and spread Preparing for COVID-19: early experience from an intensive care unit in Singapore Instructive messages from Chinese nurses' stories of caring for SARS patients Knowledge and attitudes of healthcare workers in Chinese intensive care units regarding 2009 H1N1 influenza pandemic The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned The community's attitude towards swine flu and pandemic influenza World Health Organization, 2020. Coronavirus disease (COVID-19) pandemic Will the community nurse continue to function during H1N1 influenza pandemic: a cross-sectional study of Hong Kong community nurses Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The lancet Acknowledgements: We would like to thank Sofia Russo for her administrative assistance.Funding: Nil funding for this research.Conflict of Interest: Nil conflict of interest to declare.