key: cord-0920685-kfcx0dkx
authors: He, Ling‐xiao; Ren, Hong‐fei; Chen, Feng‐jiao; Chen, Zhong‐lan; Wang, Cong; Zhang, Rui‐xue; Jiang, Yan
title: Perspectives of nursing directors on emergency nurse deployment during the pandemic of COVID‐19: A nationwide cross‐sectional survey in mainland China
date: 2022-05-16
journal: J Nurs Manag
DOI: 10.1111/jonm.13627
sha: b82f2922289b42875d2de94b0ddf58b801a9c2f2
doc_id: 920685
cord_uid: kfcx0dkx

AIMS: The aim of this study is to investigate the situation and perceptions of nursing directors about emergency nursing staff deployment in designated hospitals during the pandemic of COVID‐19 in mainland China. BACKGROUND: The pandemic of COVID‐19 has significantly depleted health care resources, leading to increased burden of nursing care and staffing and exacerbating the crisis in health care facilities. Currently, how to effectively plan and schedule nursing staffing in the pandemic still remains unknown. METHODS: From 14 July 2020 to 8 September 2020, 62 nursing directors of designated hospitals in mainland China were invited to participate in a cross‐sectional online survey for their perceptions of nursing human‐resource allocation during the pandemic of COVID‐19. RESULTS: A total of 55 valid questionnaires were collected, showing that 96.36% of the hospitals had emergency nursing organizations and management systems during the pandemic, 96.36% had well‐established scheduling principles for nursing human resources and 54.55% of hospitals had human‐resource scheduling platforms. All the hospitals had trained emergency nursing staff in infection control (55, 100%), work process (51, 92.73%) and emergency skills (50, 90.91%). Most of the participants were satisfied with the nursing staffing deployments at their institutions (52, 94.55%). However, more than two thirds of them believed that their human‐resource deployment plans need further improvements (39, 70.91%). CONCLUSIONS: Most of the designated hospitals investigated had established emergency nursing organizations, and management systems, and related regulations for the epidemic. However, the contents mentioned above still need to be further standardized. IMPLICATIONS FOR NURSING MANAGEMENT: The surge of patients in the epidemic was considerable challenge for the emergency capacity of hospitals. In the future, we should pay more attention to the following aspects: building emergency nursing staffing platforms, increasing emergency human‐resource reserves, establishing reliable communication channels for emergency response teams, improving the rules and regulations of emergency human‐resource management, offering more training and drills for emergency‐related knowledge and skills and giving more focus on bio‐psycho‐social wellbeing of nurses.

Infectious disease is a considerable challenge for the world. In the last 30 years, new infectious diseases have arisen frequently, and COVID-19 is one of the heaviest, with a mortality rate almost comparable with the Spanish flu of 1918 (Faust et al., 2020) , causing protracted damage to health systems, lifestyles, societies and economies around the world. The public health systems have faced enormous challenges after the emergence of COVID-19. The World Health Organization (WHO) suggests that it is crucial to plan the supply of quality services and redistribution of resources during the pandemic of COVID-19, focusing on prevention and responsing to COVID-19 while safeguarding essential health services (WHO, 2020) .

Nurses compose the highest proportion of staff in the global health care systems. They are the health care workers who have the most frequent contact with patients and contribute a critical component in responding to . The pandemic has resulted in increasing health care burdens and relative shortages of nursing staff (Hoogendoorn et al., 2021) , which may cause inefficient and unsafe health services. 

This study conducted a cross-sectional online survey with the Questionnaire Star online survey platform (www.wjx.cn).

This study was part of a research project on nursing staff deployment, which conducted in-depth mixed-method surveys of nursing directors, nurse managers and frontline nurses in designated hospitals across China to investigate human-resource allocation during the epidemic and further develop relevant nurse deployment criteria. The study aimed to investigate the current status of emergency nursing human-resource allocation in designated hospitals in mainland China after the outbreak of COVID-19 and the perceptions of nursing directors who are in charge of nursing human-resource management.

The inclusion criteria for the study were directors of nursing departments of public hospitals designated by the government to receive patients infected by COVID-19, who had more than 1 year of working experience in their current positions and were mainly in charge of emergency nursing staff deployment during the epidemic. Random samples of 84 designated hospitals in 31 provinces, municipalities and autonomous regions in mainland China were selected considering the representativeness of the data. The survey was conducted from 14 July 2020 to 8 September 2020. We first obtained the informed consent of the respondent after telephone and message contacts and then sent the web link of the questionnaire to the respondents through an instant messenger. Finally, a total of 62 questionnaires were distributed. We reminded the respondents 1 week later after sending the questionnaire to ensure a sufficiently high response rate.

The researchers designed a semi-structured questionnaire for this study. It consisted of 26 entries, concerning hospital characteristics (5 entries), nursing director characteristics (7 entries) and emergency human-resource deployment (14 entries). More specifically, the survey on emergency human-resource deployment survey includes give brief responses to these two questions. The survey draft was reviewed by five experts from areas such as nursing management, nursing research, evidence-based nursing, human-resource management and frontline nursing management. The draft was also revised based on the feedback from two nursing directors after a pre-survey.

This study followed the Declaration of Helsinki and was approved by the Ethics Committee of West China Hospital, Sichuan University (Ethics Approval No. 2020-198) .

The survey data were exported from the online survey platform and were analysed using thematic analysis methods, which follow the six steps Braun and Clarke (2006) proposed, to identify the themes related to emergency nursing staff deployment during the pandemic of COVID-19.

A total of 61 questionnaires were collected within the survey time limit, of which one was incorrectly filled out and five were repeatedly filled out. Hence, the final number of complete responses was 55, from 29 provinces, municipalities and autonomous regions in mainland

China. So each region responded to one to four questionnaires. should also be increased. 'In addition to the treatment nurses, the auxiliary nursing staffs are also insufficient, resulting in the nurses in isolation wards taking care of too many things, and under great pressure'

(ND19). The nursing staff's professional orientation, working ability, physical quality and mental health status should be comprehensively considered when selecting an adequate candidate for the emergency nursing manpower pool. Respondents also suggested getting more nurses specialized in infectious diseases, respiratory diseases and critical care as frontline staff reserved for the epidemic, followed by other specialties such as internal medicine, perioperative care and psychology. A multi-specialty team of nurses is more conducive to responding to emergencies. 'We need to reserve multidisciplinary nurses such as critical care, CRRT, traditional medicine, and psychology' (ND21). At the level of knowledge and skills, nurses need to be proficient with the title of supervising nurse or above and working experience for no less than 3 years. In terms of physical and mental preparation, nurses are required to be in good physical and psychological status, with a strong will to participate in epidemic preparations. 'It is recommended to transfer nurses after evaluating their psychological states' (ND35);

'Consider the physical fitness and working ability of nurses' (ND1). In addition, training on nursing skills for acute and critical illnesses should also be considered to ensure each person can be quickly activated when the epidemic breaks out, without spending too much time on temporary training. 'To better ensure the emergency human-resource deployment during the epidemic and making a rapid response, it is necessary to organize a group of reserve personnel with a reasonable structure and conduct regular training' (ND52).

In terms of manpower scheduling principles, the respondents believed that the severity of the crisis should be assessed in advance, and better to integrate each emergency nursing member into a task-oriented, multi-disciplinary functional team, which helps maximize team's efficiency, 'It is recommended to enter the isolation ward in the form of an integrated team' (ND39).

The respondents also mentioned the physical and mental support for 

Approaches such as concentrating patients in designated hospitals, planning and renovating key areas in hospital and providing highdensity medical care can help efficiently regulate and allocate relevant resources . Different hospitals have various planning for key areas. Most first-line hospitals have fever clinics and isolation wards to screen and treat confirmed cases, but some hospitals only have centralized observation areas for the screening and treating.

In fact, at the peak of the epidemic, in addition to the initial hospital system overload phase when mildly ill patients and close contacts were encouraged to be isolated at home, hospitals preferred to place mildly ill patients and close contacts under intensive medical observation to prevent further risk of community transmission. But this practice also increased the demand for nurses. There is still a lack of research on whether different regions need to further adjust their human-resource allocation according to the patient intake.

Increasing human resources can effectively reduce mortality during a pandemic (Xie et al., 2021) . And redeploying non-first-line nurses in the fight against COVID-19 can help health care organizations avoid possible human-resource crises. For example, in the ideal situation, ICUs should have a nurse-patient ratio of 1:1, but this ratio is difficult to achieve during a pandemic. Singapore has relaxed the nursepatient ratio to 1:1.3 for ICUs, promoted collaborative patient care with critical and non-critical care nurses and provided advanced training for non-intensive care nurses to ensure the quality of care. At the same time, they advocated the deployment of nursing staff from other specialties to general wards, HDUs or non-direct care positions in ICUs to fill the staff shortages caused by the transfer (Lee et al., 2020) . This procedure is also the most common practice in many other hospitals during the epidemic (Hemingway & Silvestri, 2021; Hickey et al., 2020; Lee et al., 2020; Wells et al., 2021) . By closing outpatient clinics and cancelling elective surgeries, the overall human resources are tilted towards the front line of the epidemic with high nursing needs.

Our survey found that most hospitals adopted accountable holistic approaches to patient care during the epidemic. Still, others adopted functional or other forms of care, which may be mainly due to relative shortages of nursing manpower. In fact, during the peak of the epidemic, there were shortages of frontline nurses and logistical support staff. So nurses took on heavier workloads, including daily caring routines for patients, protective materials handling and environmental cleansing, as confirmed by another study of medical aid teams in Wuhan for personnel also need to be established (Hofmeyer & Taylor, 2021) .

Health care organizations have conducted pre-service knowledge training for nursing staff deployed to the frontline, including working processes, infection prevention and control, and emergency skills. But the contents of these training and assessments are inconsistent. Considering the possible risks associated with aggregation during an outbreak, most hospitals opt for decentralized on-site or web-based training.

Some studies have shown that group distributed education can enhance learning outcomes (Marks et al., 2021) , and others have found that simulation-based training can significantly reduce nurses'

anxiety (Sullivan et al., 2021) . However, complex practice arrangements during pandemic can be labour-intensive and time-consuming.

It is not yet possible to confirm which specific training modality will better facilitate the acquisition of relevant knowledge and skills by nursing staff. In addition, training in acute and critical care skills is necessary due to the surge of critically ill patients in the COVID-19 outbreak (Wells et al., 2021) . 

Overall, most nursing directors were either very satisfied (34.55%) or satisfied (60.00%) with human-resource allocation during the epidemic prevention and control period. The results indicated no shortage of manpower from the hospital perspective, as the demand for routine outpatient and health care reduced during the epidemic, except for the frontline departments (Halcomb et al., 2020) . The problem mainly lies reasonably dispatching nurses to the frontline of the epidemic, building manpower reserve pools, determining dispatching principles and ensuring the quality of pre-training.

Managers tend to evaluate the effectiveness of nursing manpower allocation using quality of care, per capita nursing workload and nursing staff satisfaction. This also indicates that when respondents evaluated human-resource allocation during the epidemic in terms of the above aspects, they found the overall effect still satisfying.

This study still has some shortcomings. First, the survey results cannot cover all provinces entirely and may not reflect the actual situation of designated hospitals in some areas of mainland China.

Second, the study adopts an online survey format. The questions focus on describing the current status of human-resource deployment, failing to explore in-depth the difficulties encountered by managers in the process of human-resource deployment and how to solve them. In the future, further qualitative research can be conducted to explore the principles of emergency human-resource deployment. Besides, qualitative research can also be conducted to explore the principles and solutions of emergency human-resource deployment.

This study conducted preliminary research on the allocation of nursing manpower resources in designated hospitals during the peak of first round of the COVID-19 epidemic. The designated hospitals surveyed generally have different emergency nursing organizational management systems, access criteria for emergency manpower reserve, dispatching principles and pre-service training based on the hospital situation. However, the above elements still need to be further standardized.

This study found that during the peak of the first round of the COVID-19 epidemic in mainland China, most hospitals encountered shortages of nursing manpower. But through the construction of effective emergency systems and manpower reserve and scheduling platforms, the buffer capacities of the hospitals were enhanced to face the human-resource dilemma. The epidemic has highlighted the importance of nursing human-resource management, and the current medical system is not yet fully prepared. In today's global pandemic, management has gradually become standardized. We need to re-examine the nursing emergency organizations and management systems, especially concentrating on aspects such as constructing emergency nursing manpower platforms, establishing reliable communication channels for emergency response teams, increasing the reserve of emergency human resources (especially in majors such as respiratory, infectious, critical illness etc.), improving the rules and regulations of emergency humanresources management, increasing emergency-related knowledge and skills, performing more training and plan drills and paying more attention to the physical, mental and social status of nursing staff. In the future, through research on the above topics, we will try to develop better deployment plans to rationally utilize nursing manpower and improve patient experience and nursing outcomes.

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The authors gratefully acknowledge the guidance provided by Prof. 

The authors declare no conflict of interest.

This study was approved by the Ethics Committee of West China Hospital, Sichuan University (No. 2020-198) .

The data that support the findings of this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

https://orcid.org/0000-0002-7121-444XRui-xue Zhang https://orcid.org/0000-0002-1031-0139