key: cord-0803464-0ozxyyua authors: Iddrisu, Merri; Pwavra, B.P.; Ohene, Lillian A.; Ani-Amponsah, Mary; Aziato, Lydia title: Perspectives of Nurses on Preparedness for Combating Covid-19 Crisis in Ghana: A Qualitative Inquiry date: 2021-11-25 journal: Int J Afr Nurs Sci DOI: 10.1016/j.ijans.2021.100382 sha: 991dfe67580bc1c4df9cbb5fbc2e7d9cce5a0457 doc_id: 803464 cord_uid: 0ozxyyua COVID-19 has impacted negatively on people physically, psychologically, spiritually, and socioeconomically worldwide. Nurses’ ability to prepare towards case management is imperative because the potential of one coming across the virus at the hospital is inevitable. This study intended to explore and describe nurses’ perspectives on preparation towards fighting COVID 19 in Ghana. Methods: A qualitative exploratory descriptive design was adopted. Nine major health facilities designated for COVID-19 treatment centres in four regions in Ghana were involved in the study. A semi structured interview guide was used to interview twenty-nine nurses via telephone based on data saturation. Ethics approval was obtained from the Ethics Review Committee of the Nursing and Midwifery Council of Ghana. Result: data yielded two major themes and four subthemes. The two main themes were 1. Health facilities’ preparation of nurses towards COVID-19, with its subthemes; targeted training, and selection of experienced staff. 2. Nurses’ individual preparedness towards COVID-19 with the subthemes; information sourcing and sharing. Nurses in Ghana prepared for combating COVID-19 by going through training on infection prevention and control, and case management using demonstrations and simulations. Experienced nurses in Ghana volunteered to be at the frontline managing cases. Continuous updates on the virus and its management through information tracking sharing played a key role. Conclusion: Nurses in Ghana need to have more specialty training targeted at diseases of public health importance. Key words: Nurse; preparedness; covid-19. When the World Health Organization (WHO) announced that, the COVID-19 disease has become a pandemic, it caused a lot of fear, anxiety, and a feeling of hopelessness and despair as well as helplessness in people due to the devastating nature of the virus and the havoc it causes (Amewu, et. al, 2020; Nelson & Lee-Winn, 2020; Upoalkpajor & Upoalkpajor, 2020) ). Countries began to prepare to combat the disease by strengthening their health systems through training and improvement in resources (Zhang, 2020) . The disease has had a physiological, psychological, spiritual, and socio-economic impact on people all over the country (González-Gil et al., 2021; Nelson & Lee-Winn, 2020; Amewu et al., 2020) . Schools were closed down, at the same time businesses came to a standstill, and international borders shut down due to the various lockdown impositions (Upoalkpajor & Upoalkpajor, 2020) . All these were measures taken to prevent the importation of the virus into the home countries or to minimize the spread of the virus. Amid all the fear and anxiety of the pandemic, the health sector never shut down, and there was nothing like virtual health care delivery services. Health workers are rather prepared passionately towards combating the disease through active training, resource mobilization, and research. Experts explain that health emergency preparedness is a strategy for a country to test and evaluate its capabilities and, or recovery from an event that puts a significant strain on its healthcare and operating systems (Puryear, & Gnugnoli,2019; Kinyanjui, et al.,2018) . In the West African sub-region, about 300 million people are subjected to frequent emergencies like the 2014 Ebola epidemic in Sierra Leone and the 2018 floods that occurred in Nigeria (World Health Organization, 2018) . These emergencies usually come with an increasing death toll (Hussey & Arku, 2020) . The grave areas of health emergency preparedness are; pre-hospital emergency preparedness, in-house emergency response plans, human capacity building and, the assessment of existing infrastructure in emergencies (Khan et al., 2018; Stoto, Nelson, Savoia, Ljungqvist, & Ciotti, 2017) . The impact of these health emergencies can be minimized remarkably when adequate preparations are made. Well-trained healthcare personnel, structured hospitals, and proper functioning medical supplies form major constituents of good emergency preparedness. However, Sub-Saharan African countries including Ghana do not have adequate structures to mitigate health-related crises (Afriyie et. al, 2020) . It is noted that, the ability of African nations to manage infectious disease outbreaks has mainly been the responsibility of high-income countries (Makoni, 2020) . Certainly, a country like Ghana needs enormous external assistance to contain the current COVID-19 pandemic. Nonetheless, the critical roles of local leadership and communities cannot be overstressed. The current crisis provides a unique opportunity for low-and middle-income countries that are affected and those that are not yet affected to make advances on creating culturally and contextually relevant solutions to build resilience and strengthen health systems for outbreak control (Khan et al., 2018; Leinhos et al., 2014) . This will require significant investment and support to provide infrastructure, train the right personnel, raise standards of hygiene and protection in communities and healthcare facilities. There should be mechanisms in place for coordination and collaboration across sectors, and to enlist the people on the frontline in families, communities, and healthcare facilities as allies in the process (Nyarko et al., 2015) . The aftereffects of the 2014-2016 West Africa Ebola Virus Disease outbreak, propelled the WHO to call on all countries to create a strong united system that can be responsive and proactive to any imminent health threat. Sadly, evidence has it that, Ghana is not prepared for such threats (Makoni, 2020; Paintsil, 2020) . Resilient systems have been defined as bodies that rapidly obtain data about their environments, speedily adjust their behaviors and structures to changing conditions, communicate effortlessly and thoroughly with others, and generally marshal networks of expertise and material support (Stoto et al., 2017) . Ghana needs a practical national hospital and medical emergency response programmes and trained emergency medical personnel (Amu & Nyarko, 2016) . In 2012, a study conducted among hospitals in the then ten regions of Ghana on emergency preparedness reported that, the majority of the medical and allied health personnel lacked competence in emergency care. Also, medical supplies were inadequate (Norman, Aikins, Binka, & Nyarko, 2012) . The study further stated that, if nothing is done immediately to improve the weak healthcare system in the country, Ghana will observe dangerous outcomes if the country experiences any health emergency. It was then concluded that, Ghana may not survive a massive health emergency if it occurs (Norman et al., 2012) . Agreeably, the findings of Nyarko et al., (2015) revealed that, Ghana is not prepared for health emergencies with a certain magnitude just like many African countries. Nurses and midwives form a majority of the workforce in the healthcare industry and form mainly the frontline health workers who work 24hours to give care, prevent disease complications and preserve lives (WHO, 2019). In the events of an epidemic, the nursing and midwifery professions are the leading workforces at risk of contracting the disease because they work around the clock (Nelson & Lee-Winn, 2020) . We deemed it necessary, therefore, to explore nurses' and midwives' perspectives on their preparation towards fighting a pandemic. The aim of this study, therefore, was to describe the perspectives of nurses and midwives in their preparation for emergency management in a crisis given the COVID-19 pandemic. The study used a qualitative exploratory descriptive design to investigate the phenomenon. The approach was deemed appropriate because this is the first time such a phenomenon on a pandemic is being investigated among nurses in Ghana hence, an exploratory descriptive approach is useful (Polit & Beck,2014) . This research was conducted in four regions at nine different government-funded hospitals designated for confirmed COVID-19 case management. These settings were purposively selected based on the focus of the study, which was to assess nursing workforce preparedness during the Covid-19 pandemic. These hospitals were the Greater Accra Regional Hospital, the Ga East Hospital, the University of Ghana Hospital, the University of Ghana Medical Centre, the Tema General Hospital, the Komfo Anokye Teaching Hospital, the Kumasi Government Hospital, the Tamale Teaching Hospital, and the Wa Regional Hospital. These hospitals were the first centres set up around the country to receive suspected and confirmed cases of COVID-19. The research population included all ranks of nurses who worked at the emergency departments and treatment centres designated for COVID-19 suspected and confirmed cases. Twenty-nine participants were recruited to participate in this study through purposive and snowball sampling techniques as determined by data saturation (Saunders et al.,2018) . Purposive sampling was used to identify key participants. Through the key participants, other participants were recruited by snowballing. In all, four (4) participants were interviewed from the Greater Accra Regional-Hospital, four (4) from the Ga East Hospital, five (5) from the University of Ghana Hospital, two (2) from the University of Ghana Medical Centre, four (4) from the Tema General Hospital, two (2) from the Komfo Anokye Teaching Hospital, three (3) from the Kumasi Government Hospital, two (2) from the Tamale Teaching Hospital and three (3) From the Wa Regional Hospital. All nurses and midwives working at the demarcated COVID-19 isolation and treatment centers selected across the country who consent to be part of the study were recruited. Student nurses and midwives, and orientation nurses and midwives working at the selected centres were excluded. Qualitative data was collected through individual in-depth interviews from April to May 2020. To ensure the trustworthiness of the data, the interviews were guided by a set of questions the researchers prepared beforehand. The researchers contacted the nurse managers of the various COVID centres and informed them about the objectives of the study. Their assistance was sought to help recruit participants for the study. Before the data were collected, the researchers first established rapport with participants and acknowledged them. Participants who consented to participate in this research were engaged in a one-on-one individual telephone interview. Each Interview lasted between 30 minutes to one hour. All the interviews were conducted in English and audio recorded with participants' permission. During the interviews, participants were asked to share their experiences regarding their preparedness to ensure safety and wellbeing in the face of the novel coronavirus pandemic. Some of the questions asked include: How have you prepared to face COVID-19 cases? Please tell me what you have been doing since you heard of this disease? Kindly share with me how you stay informed in this crisis, and; What management strategies did you partake in? Data collection ended at saturation when no new concepts relevant to the study objectives emerged (Fusch, & Ness,2015) . Audio-recorded interviews were transcribed verbatim. The transcriptions began after the first interview and this continued concurrently with subsequent data collection. Data were processed anonymously with ID numbers to ensure the confidentiality of participants. All authors read the transcripts severally to familiarize themselves with the data. The transcripts were then coded by three of the authors independently using content analysis (Graneheim et al., 2017) . The coding frames were guided by the interview guide developed. NVivo computer software version 11 was used to manage the data (Bazeley, & Jackson, 2013). All five researchers reviewed the coded transcripts separately. Similar codes were grouped to form subthemes while similar subthemes were grouped to form main themes. The authors met to review the themes and subthemes that were generated until a consensus was reached on emerging themes and subthemes. In ensuring the trustworthiness of the study, the authors established a cordial relationship with the participants preceding data collection, this was to put participants at ease so that, they could speak freely. All the interviews were conducted via telephone due to the lockdown imposition in the country. During the interviews, the researchers probed participants' responses and sought for clarifications to reaffirm their narrations. The audios were recorded; the data were transcribed verbatim to increase the accuracy of participants' narrations which further increased the dependability of the findings. Participants had enough time during the interview to share extensively their take on the phenomenon. Seven (7) transcripts were sent back to participants who agreed to read their transcripts. The researchers discussed ensuring that data collected were accurate, complete, well interpreted, and findings denoted exactly what participants shared when they were being interviewed. The authors kept an audit trail and used verbatim quotations to denote what participants said and, to tried to avoid biases and subjectivities in the study. Ethics approval was obtained from the Ethics Review Committee of the Nursing and Midwifery Council of Ghana (IRC NO. N&MCIRC/0000002). Research information on this study was communicated and explained to research participants and informed consent was obtained before data collection. Respondents were informed that, they had the right to withdraw from the study at any point, without fear of punitive measure or punishment. Anonymity was maintained by assigning participants with special codes and confidentiality was also maintained (by) making sure all audio tapes, transcribed data, field notes, and documented information given by the participants were stored and data encrypted. Access to the data is restricted to the research team alone. The researchers anticipated the risk of psychological discomfort associated with memories of past or present experiences of nursing in crises and made prior arrangements for a Clinical Psychologist to provide mental health support for the participants. However, no psychological therapy was offered as no one broke down emotionally during the interview. A total of 29 nurses who work in the various COVID-19 centers across the country were recruited to take part in the study. Two major themes and four subthemes were generated from the data. The two main themes were 1. Health facilities' preparedness of nurses towards COVID-19, with the following subthemes: targeted training, selection of experienced staff, and 2. nurses' preparedness towards COVID-19 with subthemes; knowledge acquisition, and information sourcing and sharing. All the participants interviewed were nurses though the study targeted both nurses and midwives. Most of the participants were females in senior nursing positions. Below, is the detailed demographic characteristics of participants. According to the study participants, they first had training of trainers, and these trainers were supposed to train more people in preparation for COVID-19, but the sudden spread of the virus led to these trainers becoming the frontline Health staff. The training focused on infection prevention, donning and doffing of personal protective equipment (PPEs), and case management. "What happened was that we volunteered to take up the COVID-19 training as trainers' training, so we were supposed to have the training and then come back to train some more people to get us all ready for the management of the COVID-19 cases then so we found ourselves in it just after the training because cases have started coming up and then we quickly have to get in and start supporting" NIC-A4 The training of nurses and midwives started in December 2019 when China first recorded its cases and the focus was on infection prevention protocols and management of cases. The nursing and midwifery council of Ghana together with the Non-Governmental Organization took turns to train nurses to fight the pandemic. Some facilities had about two to three training sessions after Ghana started recording positive cases to get knowledge on the virus. "Yes, I think …when we recorded one case I was added to the group, I was at the essential group centre we were taking care of people living with HIV and diseases so we were trained on how to don and use the PPEs" NIC-E2 "It was when we had the outbreak that we were given some training at the hospital by our public health team about 2, 3 times before we joined the frontline and …working" NIC-D1 In addition to the series of training given to the nurses, some also had psychological preparation and orientation to an established model setting prepared for COVID-19 case management. This brought about a strong feeling of how an ideal COVID-19 treatment setting should look like. "It wasn't easy at all, we started with series of training on infection prevention protocol, so we had the chance to have a Clinical Psychologist to psyche us before we started managing the patients". NIC-C2 "I think it was last month I don't remember the exact date but it was last month. Then we went to Ga East to have a training and they orientated us on the setup, how to set up for the pandemic…we went to see how they have set-up so that we could make some changes or improve upon ours". NIC-B2 The long years of experience of the nurses in Ghana who volunteered to be frontline health workers gave them the courage to take up such a challenging task and accepted the responsibility to care for cases of COVID-19 Some participants learned about researches being done in the area of COVID-19 management and treatment of choice and protocols put in place for use. "Initially scientists didn't actually know exactly the mode of transmission and the pathogenesis, they didn't know anything about it, but they thought it was just an acute respiratory syndrome …but then eventually it's now coming out that it's even more like a blood condition …they have done trials that suggested that azithromycin and hydroxychloroquine combination was the most effective management for it so far. NIC-H1 The nurses and midwives prepared themselves based on the information they obtained from countries that first experienced the virus via news and the internet. "It wasn't easy … from the information we had outside, it is like the disease was killing people and personally I was afraid …but if only you follow the management protocols and the infection prevention protocols, you will be fine but it was not easy". NIC-C2 (Zhang, 2020) . This finding corroborates with the findings of Leinhos et al., (2014) and Fernandez, et al., (2020) . These studies reported that training for healthcare staff was integral to the management of health crises. They asserted that, refresher training sharpens healthcare personnel's skills and keeps them updated on emergency management and current trends. On the contrary, the World Health Organization (WHO) maintains that, institutional structural strengthening and the constitution of emergency response teams is the best way to get prepared for emergencies and not spontaneous personnel training (WHO, 2020) as revealed in this current study. This contrast exists probably because African countries do not experience emergencies such as a hurricane, major floods, widespread cases of flu and many other difficulties, as is experienced in the developed countries (Padli, Habibullah, & Baharom,2018; Dewan,2015) . As such(,) the urgency with which preparations are made toward the management of emergencies differs. Participants in this study were not adequately prepared for the management of COVID -19 cases in Ghana, like many low-income countries. The findings revealed that, experienced nurses volunteered to help fight against the Coronavirus in Ghana. Work experience gives a person the opportunity to build confidence for future challenges and to apply skills acquired. Drawing from the experiences acquired, while caring for patients during the Ebola outbreak in sierra-Leone, and other African countries, together with caring for Cholera patients and other infectious disease conditions (which are endemic) in Ghana, the nurses in this study were courageous and confident to volunteer to care for COVID-19 patients in Ghana. Other studies have reported similar findings and these authors identified the work experience of the health care personnel as a vital influence on the management of emergencies (Khan et al., 2018; Pusch et al., 2016; Nyarko et al., 2015 & Leinhos et al., 2014 . Most organizations are built on the backs of experienced workers. Ghanaian nurses obtained information on COVID -19 and learned about the dynamics of the virus, from multiple platforms including; WhatsApp, Medscape, Wikipedia, WHO, and Ghana Health Service platforms. In as much as sourcing for information is good, in times like this, not all the sources where they had the information are credible. Therefore, much of the information obtained might just be ordinary misconceptions and might not reflect the truth. This finding is in tandem with that of Aharon, Ruban, & Dubovi, (2020) who found that nurses rarely used scientific standards to evaluate inconsistent information on COVID-19 in Israel. Also, Brennen, et. al, (2020) found that, during the pandemic, there has been misinformation from even higher authorities to the lower level and vice versa. The coronavirus infection is new to the world, and therefore information from one source only may not give the full picture, so in looking for information, one needs to evaluate the various sources and select the best. Although studies have shown that, healthcare preparedness towards an emergency goes beyond just training. It includes well-structured health facilities and proper functioning of medical supplies, nurses in Ghana who are accepted to care for COVID 19 Cases are prepared to do so through training and capacity building. There is the need, therefore, for the Ghana College of Nurses and Midwives to train nurses in emergency and disaster nursing specialties and specialty in infectious disease management. All the interviews were conducted via telephone and therefore the researchers were not able to capture the nonverbal cues Not applicable Ethical approval for the study was obtained from the Ethics Review Committee of the Nursing and Midwifery Council of Ghana. 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The authors of this paper have no competing interest The authors self-funded the study Data from which this paper was written would be made available by the corresponding author on request. LA, MI, JP, MA, and LO came up with the topic, MA, LO, MI, and JP did the data collection and analyzed the data. LA supervised the study. MI and JP drafted the manuscript. LA, LO, and MA read the script individually and made inputs. All authors read and finally approved the script. We appreciate the nurses and midwives who accepted to be part of the study and shared their stories with us. Background: COVID-19 has impacted negatively on people physically, psychologically, spiritually, and socioeconomically worldwide. Nurses' ability to prepare towards case management is imperative because the potential of one coming across the virus at the hospital is inevitable. This study intended to explore and describe nurses' perspectives on preparation towards fighting COVID 19 in Ghana. Methods: A qualitative exploratory descriptive design was adopted. Nine major health facilities designated for COVID-19 treatment centres in four regions in Ghana were involved in the study. A semi structured interview guide was used to interview twenty-nine nurses via telephone based on data saturation. Ethics approval was obtained from the Ethics Review Committee of the Nursing and Midwifery Council of Ghana.