key: cord-0920929-h8e0ye6e authors: Lin, Yongxing Patrick; Tang, Charmaine Jinxiu; Tamin, Vincent Aditya; Tan, Lorraine Yee Ching; Chan, Ee‐Yuee title: The hand‐brain‐heart connection: ICU nurses' experience of managing patient safety during COVID‐19 date: 2021-09-02 journal: Nurs Crit Care DOI: 10.1111/nicc.12710 sha: e56791050780d0d6df0a0a44aa84cebeba7aca21 doc_id: 920929 cord_uid: h8e0ye6e BACKGROUND: COVID‐19 has challenged critical care nursing through increased critical care service utilization. This may have a profound impact on intensive care unit (ICU) nurses' ability to maintain patient safety. However, the experiences of ICU nurses in managing patient safety during an infectious disease outbreak remains unexplored. AIMS AND OBJECTIVES: To explore ICU nurses' narratives in managing patient safety in the outbreak ICUs during the COVID‐19 pandemic. DESIGN: A narrative inquiry design. METHODS: A purposive sample of 18 registered nurses who practiced in the outbreak ICUs during the COVID‐19 pandemic were recruited between June and August 2020. Individual semi‐structured interviews were conducted, transcribed verbatim, and narratively analysed. RESULTS: Findings reviewed an overarching anatomy‐specific storyline of a ‘hand‐brain‐heart’ connection that describes nurses' experience with managing patient safety during the COVID‐19 pandemic. Firstly, stories on ‘the hands of clinical practice’ revealed how critical care nursing is practiced and adapted by ICU nurses during the pandemic. In particular, ICU nurses banded together to safeguard patient safety by practicing critical care nursing with mastery. Secondly, stories on ‘the brain of psychosocial wellness’ highlights the tumultuous impact of COVID‐19 on the nurses' psychosocial well‐being and how nurses demonstrated resilience to continually uphold patient safety during the pandemic. Lastly, stories on ‘the heart of nursing’ drew upon the nurses' intrinsic professional nursing identity and values to safeguard patient safety. Specific patient tales further boosted the nurses' commitment to render safe nursing care during the pandemic. CONCLUSIONS: Through their stories, ICU nurses reported how they continually seek to uphold patient safety through clinical competence, resilience, and heightened nursing identity. RELEVANCE TO CLINICAL PRACTICE: ICU nurses require sustainable clinical resources and references such as clinical instructors, as well as visible psychosocial support channels, for ICU nurses to continue to uphold patient safety during COVID‐19. Recent memories of SARS, H1N1, and the Ebola pandemic have demonstrated the immense impact of public health emergencies on health systems worldwide. 1,2 On 11 March 2020, the 2019 coronavirus is declared by the World Health Organisation to be a global pandemic. 3 Early studies from China and Italy have reported a high incidence of acute respiratory distress syndrome (17%-29%) and critical illness (23%-32%). [4] [5] [6] [7] Indeed, such rapid trajectory and nature of these pandemics often become a catalyst for health systems to implement swift and decisive changes to secure population health through minimizing mortality rates and enhancing public health. 8, 9 2 | BACKGROUND The COVID-19 pandemic hence impacts health care delivery on multiple fronts; the rapid disease and clinical progression of COVID-19 signals that more patients will require critical care services for prolonged periods. Intensive care units (ICUs) will then be challenged to manoeuvre around resource limitations, infection control, staff safety, and adaptation of critical care services while ensuring patient safety in a rapidly evolving pandemic situation. Existing evidence has identified organizational factors and teamwork as predictors of patient safety. 10, 11 This was further reinforced by previous nurses' narratives that the nursing practice environment impacts their perceived adequacy of care. 12 Recent evidence has also demonstrated that ICU nurses reported the dehumanization of care provision during the COVID-19 pandemic, 13, 14 which in turn may threaten patient safety. These prominent findings highlighted the importance of understanding the specific context and environment in which nurses deliver patient care. However, there is a dearth of evidence on how ICU nurses storied their accounts on how they manage patient safety during a pandemic situation. Understanding how ICU nurses manage patient safety during an infectious disease outbreak holds strong promises for nurse leaders to render targeted interventions to support ICU nurses in managing patient safety. This thus pave the way for the current study to explore ICU nurses' narratives of managing patient safety within the context of the COVID-19 pandemic. This study aims at exploring ICU nurses' narratives of managing patient safety during the COVID-19 pandemic. This study adopted the Riessman 15 • ICU nurses positioned within the outbreak ICUs will need to navigate across a complex critical care environment to uphold patient safety. • Nurses' narratives on how they manage patient safety in the ICU during the COVID-19 pandemic have not been explored yet. What this paper adds • Nurses described managing patient safety in the ICU as a balancing act of providing critical care nursing reflected against their psychosocial wellness and nursing identity. • By understanding the ICU nurses' narrative of how they manage patient safety during an infectious disease outbreak, tailored interventions such as providing clinical support can be implemented and evaluated. characteristics of social context, time, and place. This article follows the Consolidated Criteria for Reporting Qualitative Research (COREQ). 16 This study is conducted in the outbreak ICUs of a 1900-bedded tertiary hospital and 330-bedded purpose-built infectious disease facility in Singapore. Serving as the epi-centre of the COVID-19 management in Singapore, the hospital sees close to 75% of all COVID-19 cases nationally. Since the COVID-19 outbreak, dedicated outbreak ICUs were operationalized to house suspected and confirmed COVID-19 patients who required intensive care. These outbreak ICUs were intended for use during an infectious disease outbreak or to house ICU patients with novel pathogens. In the absence of an infectious disease outbreak, these ICUs functioned as medical ICUs. Each patient room within the outbreak ICUs features infrastructure barriers such as an anteroom and automated inter-locking doors. The patient room is negatively pressured in relation to the anteroom and corridor to prevent contamination and transmission. In anticipation of the surge in ICU bed demands during an infectious disease outbreak, the outbreak ICUs have the relevant infrastructure to support up to 220 ICU beds. In tandem, ICU nursing manpower was also mobilized from various sources. Firstly, non-outbreak ICU nurses were deployed into the outbreak ICUs. Next, the Singapore Ministry of Health arranged for a team of ICU nurses from other local hospitals to be deployed into outbreak ICUs. In total, over 150 ICU nurses were deployed to support the outbreak ICUs during the COVID-19 pandemic. In addition, over 550 general ward nurses were also mobilized to provide nursing support in the ICUs. The participants were drawn from the pool of ICU registered nurses comprising of the outbreak ICU nurses, as well as nurses who were deployed in from the non-outbreak ICUs and local hospitals. These nurses who were working in the outbreak ICUs during the COVID-19 pandemic were informed about the study through their nurse managers and recruitment flyers. Nurses in supervisory positions such as nurse managers, nurse clinicians, and nurse educators were excluded to obtain a focused narrative of ICU nurses who are providing direct patient care during the COVID-19 pandemic. A purposive sample of registered nurses, who were agreeable to study participation, were recruited. Using maximum variation sampling for their years of nursing experience as well as clinical background (outbreak ICU nurse, deployed non-outbreak ICU nurse, other local hospitals' ICU nurse), the study team aimed at yielding diversity in experiences regarding the management of patient safety during the COVID-19 pandemic. Data collection took place from June to August 2020. Before interview commencement, participants were invited to complete a demographic questionnaire to obtain information on their age, clinical role, critical care nursing experience, and previous experience in outbreak management (eg, H1N1). Thereafter, a one-time, individual, face-toface interview was conducted with aid of a semi-structured interview guide with each participant. The interview guide was pilot-tested before study commencement. All interviews were conducted in English by a trained researcher (YPL) who had no dependent relationship with any of the participants. Interviews took place in a private room away from the clinical area, were audio-recorded, and lasted between 32 minutes and 53 minutes. Field notes were taken during and after the interviews to document the researcher's reflections and nonverbal, observational data such as body language and expression of the participants. 17 The interviewer sought to clarify meanings and interpretations during the interview itself. This acknowledges the element of time and space crucial in narrative research and to protect the 'wealth of detail' in the narratives. 15 Data collection occurred concurrently with data analysis until data saturation, wherein no new further information arose from the data. 18 The study team acknowledges that exploring patient safety issues can lead to recounting of previous negative encounters such as failure of care provision or even adverse patent events. The sensitive nature of the interviews hence signifies a potential threat to participants' psychological well-being. 19 Hence, to safeguard participants against any psychological trauma, the study team collated a list of resources that the interviewer was ready to refer distressed participants to. These resources include a list of para-counsellors within each department, as well as psychosocial support channels helmed by social workers within and beyond the institution. Prior to the interviews, participants were informed that they can stop the interview at any time. In addition, the senior researcher of the team provided coaching to the interviewer to identify signs of participant distress. All audio recordings were transcribed verbatim and narratively analysed. 15 Transcripts were not returned to the participants for comment. Data are first categorized by participants, and then read and reread to gain and re-sensitize an in-depth understanding of each participant's narration. The data are then inductively analysed by two researchers (YPL, VAT) independently and examined across the continuum of patient safety, with narratives fitting the overarching foci of patient safety identified through manual coding (Data S1). Each narrative sequence was preserved and presented as shared by the participants. 15 This ensures that the resulting evolving narrative truths are situated within the context of the outbreak ICU during the COVID-19 pandemic. Field notes taken during the interviews were also referred to during the data analysis phase. A coding schema and map are then generated to give rise to the patient safety-specific storylines. Data saturation was achieved after 15 participants. A further three more interviews did not reveal any new storylines, but rather, deepened the understanding of the intricacies of managing patient safety in the outbreak ICUs. Strategies to ensure trustworthiness in this study were implemented in accordance with the recommended guidelines by Lincoln and Guba. 20 Independent data analysis by two researchers and clarifying meanings during the interviews strengthened credibility. Having the lead researcher (YPL) conduct all the interviews promoted dependability. An exhaustive write-up of the narrative storylines, together with the participant demographics, facilitated transferability. To promote confirmability of the findings, the lead researcher maintained a reflexive diary of his reflected thoughts and an audit trail for the study. The reflexive measures adopted also ensured constant 'wakefulness' during the study. 21 Ethical approval was sought from the National Healthcare Group Domain Specific Review Board (Reference No: 2020/00317) prior to study commencement. Informed consent was obtained from each participant prior to the interview. Their right to withdraw from the study at any time was reinforced to the participants. Consistent pseudonyms were used across the audio-recording and transcripts to ensure confidentiality. Eighteen nurses, comprising of 13 females and 5 males, were interviewed. There was no refusal to participate or drop out during the study. Their years of nursing experience ranged from 2 to 10 years. A summary of their demographic characteristics is shown in Table 1 . The nurses' narratives of managing patient safety in the outbreak ICU are presented according to three anatomy-specific storylines of the hands, brain, and heart as shown in Figure 1 . While the storylines are delineated clearly from one another, they share similarities in managing patient safety in the outbreak ICU. Maintaining patient safety through clinical practice in the outbreak ICU was characterized by personal stories of nursing practices and how nurses 'nurse' their patients during the COVID-19 pandemic. Throughout their stories, nurses constantly mentioned instances of how COVID-19 changes the way critical care nursing is being practiced. 'Nursing a COVID patient in ICU, the situation is different now; you have to cope with many things', Rachel explained. Through their stories, it was clear that nurses have experienced how differences in nursing care provision during the COVID-19 pandemic could have impacted patient safety. A distinct example was raised by Oliver, when she described her experience with attending to a patient receiving renal replacement therapy; 'it will take more time to enter the patient's room; there was once when my patient was on dialysis and the heart rate crashed to 30 (beats per minute). But I cannot run in; T A B L E 1 Demographic information of participants In addition, for many nurses, the intensity of how critical care nursing is being practiced during a pandemic greatly impacted patient safety. Reflecting upon the patient acuity, anecdotes soon emerged on how the nurses observed patients becoming even more critically ill than before. Nurses found themselves no longer being able to practice solely as a medical, cardiology, neurology, or surgical ICU nurse as they used to. Instead, nurses were thrust into a position where they had to practice multisystem critical care nursing with mastery. As Janice discovered, 'I find that there is more multi-organ involvement as compared to usual. They tend to get abdominal issues… renal (and) hematologic complications… So, it is more complex'. In making sense of their nursing practice to safeguard patient safety, nurses located their stories heavily within the nursing work- In contrast to the storylines of the hands of clinical practice, stories of the brain were embroiled with the emotional turmoil of seeing the to be proud about being in this kind of pandemic. The main thing is that you get to work as a team, and you get to learn from the pandemic'. This study explored the narrative accounts of nurses managing patient safety in the outbreak ICUs during the COVID-19 pandemic. Our findings revealed that patient safety is under sustained threats and mediators as narrated by the nurses. These narratives shape the storylines within the context of the outbreak ICU during the COVID-19 pandemic. A salient recurring, narrative was the implications of the mass deployment of nurses into the outbreak ICUs. Our study setting saw mass nursing deployment from the non-outbreak ICUs as well as the other national hospital ICUs, which is consistent with current manpower strategies adopted worldwide, where nurses from non-outbreak departments are deployed into the outbreak ICUs. 22 The findings of this narrative study have various implications for nursing practice and recommendations for future research. Firstly, nurse leaders will need to recognize that with massive manpower deployment into the ICUs, there will be a possible dilution in the critical care workforce with deployed ICU nurses or non-critical care nurses during the pandemic. Even with the deployment of ICU nurses from external sources, there will be differences in clinical practices and unfamiliarity with ICU equipment. Hence, nurse leaders will need to ensure the availability of clinical instructors or clinical resources to support nurses' capabilities in maintaining patient safety in the ICUs. Secondly, while our findings reported that the ICU nurses were able to practice critical care nursing with resiliency, an air of melancholy described by the ICU nurses necessitated ongoing psychosocial support measures such as counsellors and para-counsellors to be made visible to the ICU nurses. Thirdly, while health system leaders laud the contribution of the nursing profession to safeguard patient safety, it is crucial to accord the nurses with favourable working conditions and to avoid spinning the nursing profession into a self-sacrificial rhetoric. Lastly, future exploration into the interprofessional collaborative practices in the context of a pandemic situation can signal strong potential for improving patient safety during outbreak situations. As nurses assume frontline duties at the forefront of patient care during the COVID-19 pandemic, ICU nurses narrated stories of how their nursing practices, psychosocial well-being, and professional identities shaped their experiences of managing patient safety in the ICU. It is vital to note that nurses reported how the intensity and way critical care nursing is practiced during the COVID-19 pandemic can impact patient safety. In addition, ineffective psychosocial coping of nurses in the face of death and dying can have dire consequences for nurses to maintain patient safety for critically ill patients. Organizational strategies such as the availability of clinical nurse specialists to provide clinical supervision and para-counsellors to promote psychosocial wellness can be beneficial for ICU nurses during the COVID-19 pandemic. SARS: Governance and the Globalization of Disease Epidemic: Ebola and the Global Scramble to Prevent the Next Killer Outbreak World Health Organisation. 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We would also like to thank the deployed ICU nurses from the National Healthcare Group, National University Health Services, and Singapore Health Services for supporting the Outbreak ICUs. Yongxing Patrick Lin contributed to conceptualization, data collection, and data analysis, wrote the original draft, and reviewed and edited the manuscript. Charmain Jinxiu Tang and Vincent Aditya Tamin helped with data analysis, and reviewed and edited the manuscript. Lorraine Yee Ching Tan helped with conceptualization, and reviewed and edited the manuscript. Ee-Yuee Chan performed conceptualization and supervision, and reviewed and edited the manuscript. Research data are not available.