key: cord-0795312-tcix6nls authors: Rasmussen, Bodil; Holton, Sara; Wynter, Karen; Phillips, David J.; David, Jennifer L.; Rothmann, Mette Juel; Skjoeth, Mette Maria; Wijk, Helle; Frederiksen, Kirsten; Ahlstrom, Linda; Anderson, Janet E.; Harris, Ruth; Conolly, Anna; Kent, Bridie; Maben, Jill title: We're on mute! Exclusion of nurses' voices in national decisions and responses to COVID‐19: An international perspective date: 2022-03-29 journal: J Adv Nurs DOI: 10.1111/jan.15236 sha: c08f502d26774f542e78647fd639db51e22acecf doc_id: 795312 cord_uid: tcix6nls nan We work clinically and conduct nursing and health services research in several high-income countries (Australia, Denmark, Sweden and the United Kingdom) which have relatively high COVID-19 vaccination rates by world standards but have reported varying numbers of COVID-19 cases and deaths and implemented diverse responses to the pandemic. At the end of January 2022, the total confirmed COVID-19 deaths per million people in Australia and Denmark were below the world rate compared with higher rates in Sweden and the United Kingdom. Sweden has implemented fewer and less stringent restrictions than the other countries in which we work. The Swedish response was based on pragmatism, 'common sense' and personal responsibility. Schools and borders remained open, and no 'lockdowns' were implemented. In contrast, Australia, Denmark and the UK introduced many initiatives to limit or slow infection transmission. These included stringent 'lock-downs, 'social' (physical) distancing, remote working for non-essential workers and remote learning for school-aged children and university students, the closure of international borders and restrictions to visitors in healthcare settings including hospitals and aged care. Additional income support was provided by government for those unable to work due to COVID restrictions. COVID-19 vaccinations for healthcare workers such as nurses were also mandatory in Australia. In the UK they were mandated for social care workers, but this requirement was dropped for NHS staff in early 2022. Nevertheless, our research demonstrates the universal and considerable psychosocial impact of the COVID-19 pandemic on nurses internationally. About 20%-30% of the nurses we surveyed during the first wave of the pandemic reported mild to extremely severe psychological distress (Couper et al., 2021; Holton et al., 2020; Holton, Wynter, Rothmann, et al., 2021) . Nurses also appear to have experienced greater psychological distress compared with other healthcare workers. Our study of hospital clinical staff conducted in Australia found that nurses and midwives were significantly more likely to experience symptoms of anxiety than doctors and allied health staff (Holton et al., 2020) and this association remained as the pandemic continued (Wynter et al., 2022) . In Sweden, registered nurses reported more negative effects of the pandemic on their working conditions and ability to recover than other professional groups (Alexiou et al., 2021) . This high level of psychological distress may have been exacerbated by reports of nurses dying due to COVID-19 estimated in October 2020 to be 1500 across 44 of the world's 195 countries (International Council of Nurses, 2020). As well as high levels of psychological distress, the pandemic has also had a negative effect on nurses' work and personal lives. Nurses in all countries have reported concerns about contracting COVID-19, putting colleagues and family members at risk and caring for infected patients; the challenges of wearing and lack of access to personal protective equipment; the stress of being redeployed to other areas and undertaking different duties than normal; difficulties managing paid work and family responsibilities, including supporting children with remote learning; and experiencing moral distress when they are unable to deliver the care they wish to (Couper et al., 2021; . prime minister, paid special tribute to the nurses 'who stood by [his] bedside for 48 h when things could have gone either way' when he was hospitalized for COVID-19 early in the pandemic . In Denmark, Her Majesty Queen Margrethe II paid tribute to healthcare workers including nurses in her 2021 New Year's Address: 'many people must again make an extra effort. This applies in particular to those who help trace and limit infection, and to those who treat the sick' (HM The Queen of Denmark, 2021). In Sweden, nurses were recognized with 'official national applause' (as in the UK) and Swedish nurses received additional salary payments during different waves of the pandemic. Yet despite their raised profile, nurses' voices are seldom heard or considered in COVID-19 decision-making and responses. highlighted the lack of input that many nurses feel they have in COVID-19 decisions. One participant commented: 'Feeling like things are being planned behind the scenes that will perhaps affect us but perhaps we're not included during the planning stages…' . Our research in the UK identified that nurses frequently tried to raise concerns during the pandemic but an 'organizational deafness' existed which meant that their concerns were ignored (Adams et al., 2020) . Many of the nurses we interviewed spoke about their moral distress at being ignored and silenced and some left the NHS as a result. One very senior nurse reflected on her experience of being redeployed to a national role during the pandemic. She stated that the government paused the interventions she had been involved in recommending and as a result, she stepped down from her role. to very senior people. I didn't get a response. Not even a reply'. Similar to other nurses we spoke to who did not hold such senior positions, she felt ignored and undervalued (Maben et al., under review) . As highly educated and skilled health professionals, who spend most time with patients and are critical to patient safety, it is vital that nurses have a voice in high level decisions about the response | 3 EDITORIAL and planning for not only the COVID-19 pandemic, but also future health crises and adverse events. Nurses have unique healthcare expertise, intimate knowledge of healthcare systems, work in a variety of healthcare settings, are powerful patient advocates and have unique perspectives of patients' experiences. They need to be actively involved in the COVID-19 response, and response to other health challenges, to ensure effective decision-making, better patient outcomes, high quality and patient-centred care, and more robust healthcare systems. We need to value and empower nurses, recognize the important role Nurses around the world have made a considerable and valuable contribution at the point of care delivery during the COVID-19 pandemic, often at significant cost to their own psychological well-being and personal lives. Yet overwhelmingly they have had a limited voice in the national and regional responses to the COVID-19 pandemic in our respective countries. We believe nurses' can, and should, play an integral role in driving the conversation about the management of and response to the COVID-19 pandemic and other future adverse health events. A diversity of voices and expertise is critical for effective decision-making in times of crisis, benefitting collective action and ultimately patient care. It is time to make sure our mics are on and to turn up the volume! The authors are most grateful to all the nurses who have participated in our research. How do "heroes" speak up? NHS staff raising concerns during covid-19 A survey of psychiatric healthcare Workers' perception of working environment and possibility to recover before and after the first wave of COVID-19 in Sweden Boris Johnson praises immigrant nurses who saved his life, as Britain's NHS becomes a rallying cry The impact of COVID-19 on the wellbeing of the UKnursing and midwifery workforce during the first pandemic wave: A longitudinal survey study Her majesty the Queen's new year address 2021. 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