key: cord-0771109-da1byb9t
authors: Tashkandi, Nabeeha; Aljuaid, Maha; McKerry, Theolinda; Alchin, John; Taylor, Laura; Catangui, Elmer J.; Mulla, Rana; Sinnappan, Suwarnnah; Nammour, Georges; El-Saed, Aiman; Alshamrani, Majid M.
title: Nursing Strategic Pillars to Enhance Nursing Preparedness and Response to COVID-19 pandemic at a Tertiary Care Hospital in Saudi Arabia
date: 2021-07-02
journal: J Infect Public Health
DOI: 10.1016/j.jiph.2021.06.016
sha: ef29e8b428de05accd25d4a3b2dfe6d8b0536964
doc_id: 771109
cord_uid: da1byb9t

BACKGROUND: COVID-19 pandemic caused enormous implications on the frontline staff. The objective was to share our nursing experience in responding to COVID-19 pandemic at a large hospital and its impact on nursing safety and healthcare services. METHODS: Six nursing strategic pillars were implemented. Pillar 1: Establishing Corona Command Centre. Pillar 2: Limiting exposure by virtual care model, strict infection control measures, altered patient flow, active surveillance, and contact tracing. Pillar 3: Maintaining sufficient supplies of personal protective equipment. Pillar 4: Creating surge capacity by establishing dedicated COVID-19 units and increasing critical care beds. Pillar 5: Training and redeployment of nurses and implementing alternate staffing models. Pillar 6: Monitoring staff wellbeing, establishing mental health support hotline and clinic, providing hotel self-quarantine, and financial incentives. RESULTS: Out of 5,483 nurses, 543 (10%) were trained for redeployment, mainly at acute and intensive care units. After serving 11623 infected patient including 1646 hospitalizations during the first 9 months of the pandemic, only 385 (7.0%) nurses were infected with COVID-19. Out of them, only 10 (2.6%) required hospitalization, one (0.3%) required ICU admission, and none died. Although the number of patients hospitalized at our hospital during the current pandemic was 17 folds higher than the 2015 outbreak of middle East respiratory syndrome coronavirus, the hospital administration did not have to close the hospital as they did in 2015. CONCLUSIONS: Proactive nursing leadership and implementation of multiple nursing pillars enabled the facility to maintain the safety of nursing workforce while serving large influx of COVID-19 patients.

Since the first case in late 2019, more than 170 million patients were infected with coronavirus disease-19 (COVID-19) with 3.7 million deaths by the end of May 2021 [1] . The recorded number in Saudi Arabia during the same period was 450 thousand infections and 7500 deaths [2] . Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a variable clinical spectrum ranging from asymptomatic infection to severe pneumonia and life-threatening complications, specially with other comorbidities [3] . The emergence and spread of multiple new variants of SARS-CoV-2 represent a major challenge to stop the pandemic [4] .

COVID-19 pandemic caused enormous implications on healthcare system, particularly on the frontlines such as nursing workforce [5] . They are at higher risk of exposure and infection than the rest of the community [6] . Additionally, they frequently suffer from burnout, psychological diseases, and sleep disturbance [7] . In addition, the large influx of patients to healthcare system result in heavy utilization of healthcare resources, specially intensive care units [8] . Nevertheless, the role of healthcare workers continue to be critical for the response to the pandemic [9, 10] . They fight to get their job done while prevention spread of infection to patients, coworkers, and families [9, 10] . They have to extend their working hours to respond to the high patient volume, get additional training so can serve critical tasks, and get familiar with remote education and telemedicine [9, 10] . Additionally, they have to work while wearing full personal protective equipment [9, 10] .

Nursing leadership was engaged at the executive level on setting nursing strategic pillars to enhance nursing preparedness and response to the COVID-19 pandemic at various levels. The pillars represent a modification of nursing and healthcare transformation plans effectively used during and after controlling 2015 MERS-CoV outbreak [11, 12] . Although the nursing pillars J o u r n a l P r e -p r o o f represent an extension of local nursing experience accumulated after the 2015 MERS-CoV outbreak [11, 12] , they were perfectly aligned with recommendations for efficient utilization and surge of nursing manpower during crisis [13, 14] . Additionally, all measures taken to achieve these pillars were continuously monitored and modified to minimize the risk to nursing workforce, patients, and the system. The current paper will highlight nursing strategic pillars set and practiced during the COVID-19 pandemic at MNGHA hospital. Additionally, the impact of these pillars on nursing safety and healthcare services will be discussed.

Leadership and in place response plan is critical to sustain health workforces during the time of pandemic [15] . Therefore, the Ministry of National Guard Health Affairs at Riyadh [12, 16] . As many healthcare institutions in Saudi Arabia, previous experience with MERS-CoV strengthened MNGHA's ability to manage emerging infectious disease outbreaks [17, 18] . Weekly virtual meetings were conducted by all 

To ensure patient and healthcare safety as well as appropriate risk management, MNGHA swiftly moved into implementing strict safety measures at an early stage during COVID-19 pandemic.

The aim was to minimize the exposure and reduce the transmission of infection among patient and healthcare workers. Nurses were diligently involved in decisions and implementations of these safety measures, to reinforce their role in COVID-19 response [19] . 

One of the major challenges across the globe caused by this pandemic was the shortage of personal protective equipment (PPE) [20, 21] . Several strategies have been suggested to overcome the PPE shortage including; manufacturing own PPEs from domestic materials such as fabrics for masks and plastic bags for gowns, extending the life of available PPEs, and reducing J o u r n a l P r e -p r o o f nonessential services [22] . Fortunately, the MNGHA was able to maintain required essential PPE supplies to ensure that staff caring for patients always had the highest level of protection.

The ability to maintain these supplies throughout the surge of COVID-19 cases has had a major impact on the organization's ability to manage resources safely and effectively during the outbreak. MNGHA command center established a robust mechanism to ensure availability of COVID-19 supply at all clinical units, with a focus on reducing nosocomial infection between patients and healthcare workers. The aim was to ensure that the organization is able to maintain its workforce with minimal impact from sick leaves and quarantines due to unprotected exposure. In addition, to maintain physiological well-being of the frontline staff, which has a positive impact on morale. Staff who are protected are more confident in delivering care and therefore willing and able to deliver better care [23] .

Nurses were represented in a taskforce committee who worked closely with the nursing products team to facilitate the supply of COVID-19 PPE to all targeted clinical areas. Following the MERS outbreak in 2015, MNGHA mandated attendance for all clinical staff of PPE sessions.

The focus of these sessions were to improve understanding of the different levels of isolation (e.g. contact, droplet, and airborne isolation), improve understanding of required PPE to manage different levels of isolation, and to demonstrate the correct process for donning and doffing of PPE. Additionally, all clinical staff were also mandated to attend N95 fit testing program every two years. Staff who failed the fit testing using different sizes of masks were referred to [24, 25] , the US Food and Drug Administration (FDA) [26] , the Saudi Food and Drug Administration (SAFDA) [27] and MOH guidelines [28] . These strategies helped MNGHA to ensure a continuous supply for its frontline healthcare workers in an exceedingly difficult global supply environment.

Once a healthcare organization is unable to meet the needs of patients with existing resources, the creation of surge capacity is a must [29] . There are three essential components to surge capacity i.e. staff, equipment and structure. Nursing preparedness plan focused on equipment and structure, more specifically creation of additional bed capacity using various strategies. It focused on the strategic management that aims to accommodate the increased surge capacity and facilitate the seamless admission/transfer of confirmed and suspected COVID-19 cases into appropriate units. Empirically, the idea is to prevent cohorting two different groups of patients in order to avoid cross contamination [30] .

In both MNGHA and Saudi Arabia, the highest prevalence of confirmed COVID -19 cases was observed during the months of May and June 2020 [31] . As the number of COVID-19 patients increased, the demand for beds comparably increased, resulting in the need for the already planned surge capacity. In order to meet this need, pandemic, MNGHA had one critical care unit (8 beds) and one acute care unit (29 beds) dedicated for patients with acute respiratory illnesses. Creating capacity for critical care beds, required reconstruction of wards to facilitate the complex care and equipment required.

Furthermore, multiple negative pressure rooms were created in all the designated COVID-19 units. Where this was not possible, high-efficiency particulate air filters were used. Entrances to these units were restricted and all staff were screened for temperature and any acute respiratory illnesses prior to be allowed entry.

Another used strategy to increase the surge capacity was to suspend elective admissions, day cases and surgeries. Previous experience with influenza pandemic pointed that this strategy may not be enough as the increasing admissions would exceed the reduction created by these measures [32] . This proved to be the case in MNGHA, however this challenge was met with the establishment of quarantine hotels. Collaboration between MNGHA's Corona Command Center and regional bodies led to the establishment of interim hotel accommodation to "cured" COVID-19 patients who did not require long-term hospitalization.

Workforce planning is a critical element in preparing for uncertainty in times of a pandemic such as COVID-19 [33] . At MNGHA, the focus for nursing leadership included strategies for optimizing staffing resources, maintaining staff safety and resilience and the efficient provision of evidence-based care. The strategies employed included; the training and redeployment of nursing staff, implementation of alternate staffing models, adjustment of nurse to patient ratios (NPR) and scheduling patterns, introduction of extended hours for senior nursing leadership, monitoring nursing absenteeism, and facilitating return of stranded staff..

During the pandemic, 543 (10%) out of 5,483 nurses were trained for redeployment at MNGHA. This was accomplished through a step by step process; first identifying alternate J o u r n a l P r e -p r o o f internal sources of staffing, followed by identifying the knowledge, skills and practice gaps required for the staff for each of the different training programs. Focused training programs were then developed that were tailored to what was required to ensure that nurses were appropriately trained for the specialty area that they would be redeployed to [34] . The While the surge capacity secondary to infectious disease is a unique strategy to mitigate staffing shortages [35] , the partial relief produced has been challenged by many other factors that had direct impact on the availability of staffing resources. These included nursing staff stranded outside the country due to worldwide travel bans, special leave granted to nursing staff with medical conditions who were at higher risk of getting COVID-19 infection, leaves for COVID-19 positive nursing staff, and leaves related to development of symptoms. Nursing leaders closely monitored these challenges and tried to solve. They extended efforts to facilitate the return of 250 of the 300 stranded staff. Additionally, all leaves were suspended for a period of time, with the exception of local leaves for emergency purposes.

When nursing staff are redeployed during a crisis, they are usually required to work in unfamiliar work environments that fall outside of their scope of practice. Consequently, teambased capability may be more practical and efficient than individual-based capability [36] . For J o u r n a l P r e -p r o o f redeployment during the COVID-19 pandemic, nursing services opted to change from a primary nursing care model to a hybrid model including functional nursing in some of the units. This allowed for efficiency in patient care as the nurses had a clearly defined task that they could accomplish in a short period of time. The redeployed nurses worked at the direction of charge nurses, tasked with patient care activities within their competence. The critical care units developed a team-based approach for critical care patient management, where a group of redeployed staff was supervised by a critical care nurse. This allowed for the best use of the unique skill sets of each team member, providing efficient critical care to patients collaboratively. During the COVID-19 pandemic, nurse to patient ratios were adjusted to provide an appropriate base staffing. This was augmented with float staff on a shift by shift basis.

Adjusted working patterns, such as assigning shorter shifts (8-hours as opposed to 12-hours) and overtime utilization were also considered, in an effort to balance workloads and to reduce stress.

One of the challenges of any crisis is rapidly changing situations that require real time decision making and staff support. In order to mitigate this challenge, directors of nursing and nurse managers worked extended hours during the weekday as well as weekends. Critical care managers provided a 24-hour on-site presence, providing support to critical care units. This ensured that staff received direction based on real time decisions. Additionally, they received support when needed, regular updates regarding COVID-19 status, updates regarding operational changes, responses to safety concerns, and other issues related to surge capacity.

In most health care organizations across the globe, during a pandemic such as COVID-19, the focus is to ensure capacity and workforce to deal with the overwhelming surge in patient numbers. On the other hand, the pandemic impact on mental health of frontline staff often takes a J o u r n a l P r e -p r o o f back seat [29] . Therefore, it is crucial for nursing leaders to anticipate the stressors and understand the sources of anxiety and fears that the frontline staff may experience during a pandemic [37, 38] . To this end, a staff wellbeing survey was conducted at MNGHA on April 2020. Nursing staff represented 42.5% of the 11319 respondents. The result revealed that 22% of nurses were at risk of developing post-traumatic stress disorders; 21% were at risk of developing anxiety and 19% were at risk of developing depression. Furthermore, the survey revealed that 31% considering quitting their jobs or changing their career. In response to the findings of this survey, a nursing wellbeing program, "Well Resilient Nurse" was established at a corporate level to promote staff wellbeing and prevent staff anxiety, stress, and burnout. Keeping nursing staff protected from chronic stress and poor mental health during this crisis means that they will have a better capacity to fulfill their roles [37] . Currently, most organizations have passed the initial impact of the COVID-19 pandemic and the heroic phase that immediately follows [39] . Staff are now going through emotional downslope of the disillusionment phase [39] . This phase could last for months or even longer before it gradually transforms into a recovery phase. Therefore, the focus should be on the long-term mental wellbeing capacity of the frontline nurses.

In addition to sharing the nursing experience in dealing with the pandemic, it may be helpful to share some of its impact on nursing safety and healthcare services. However, lack of control group and multiple nature of the interventions challenge any tested impacts. Yet, the infection control data showed that nurses at MNGHA were doing very well while serving large influx of sick patients. For example, after serving 11623 infected patient including 1646 hospitalizations, only 385 (7.0%) nurses were confirmed with COVID-19 during the first 9 months of the J o u r n a l P r e -p r o o f pandemic ( Figure 1 ). As expected, the peak of infection coincided with patient infection and hospitalization (Figure 1 ). Out of the 385 infected nurses, only 10 (2.6%) nurses required hospital admission, one (0.3%) nurse required ICU admission, and none died. The current infection rate was better than reported in meta-analysis studies, where infection rates ranged between 10% and 11% among healthcare workers globally during the first 6 months of the pandemic [40, 41] . Similarly, the current hospitalization and ICU admission rates was much lower than reported before in the US (8% and 2%, respectively) [42, 43] . With the exception of elective admissions/surgeries, MNGHA services were maintained during the pandemic.

Although the number of patients served and hospitalized at MNGHA during the current pandemic was approximately 90 and 17 folds (respectively) higher than the 2015 MERS-CoV outbreak, MNGHA administration did not have to close the hospital as they did in 2015. As 

The COVID-19 pandemic has challenged the healthcare system at multiple levels. Our experience showed that proactive nursing leadership and implementation of the proposed nursing strategic pillars enabled the facility to maintain the safety of nursing workforce while serving large influx of COVID-19 patients.

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