key: cord-0835253-wpoj1y6c
authors: Gao, Z.; Tan, F. P. L.
title: Nurses’ experiences in response to COVID‐19 in a psychiatric ward in Singapore
date: 2021-04-24
journal: Int Nurs Rev
DOI: 10.1111/inr.12680
sha: f391c78f1d50d39d7b7160f8bd47384b35c4839d
doc_id: 835253
cord_uid: wpoj1y6c

AIM: To understand nurses’ responses to COVID‐19 and identify their uptake of changes in the procedure required for the management of COVID‐19 in an inpatient psychiatric ward. BACKGROUND: The infection risk for COVID‐19 in an enclosed inpatient psychiatric ward is high due to living arrangements in the ward and the nature of the infectious disease. INTRODUCTION: This paper describes inpatient nurses’ experiences, challenges and strategies deployed at the institutional and national levels to contain the spread of infection. METHODS: Written feedback was collected to understand nurses’ responses and identify their uptake of changes in procedure following the COVID‐19 outbreak in the ward. FINDINGS: Nurses felt shocked, worried, isolated, expressed a lack of confidence, and experienced physical exhaustion. COVID‐19 specific challenges were highlighted in the delivery of safe and quality nursing care. Nurses were satisfied with the hospital policy and strategies implemented during the outbreak, acknowledging the importance of support from nursing leaders. DISCUSSION: Practical support and strong nursing leadership have been imperative in the battle against the COVID‐19 outbreak in the psychiatric hospital. Psychiatric nursing care was maintained with a modified management and treatment approach. IMPLICATIONS FOR NURSING PRACTICE: Nurses' willingness to adjust to the reconfiguration of operations to accommodate changes has been crucial for the healthcare system to run effectively. Good practices and policies established during this crisis should be developed and established permanently in nursing practice. IMPLICATIONS FOR HEALTH POLICY: Prompt and effective contingency planning and policymaking at the national and institutional level, targeting human resource management and infection control, can introduce changes and alternative options for nursing care in a pandemic. CONCLUSION: With support from influential nursing leaders, strategies and policies are imperative in ensuring the successful management of COVID situations in an inpatient psychiatric setting.

In December 2019, clusters of patients with pneumonia of unknown cause were identified in Wuhan, China ). It did not take long for the disease to infiltrate other parts of the world. In February 2020, the World Health Organization named the new coronavirus disease COVID-19 (World Health Organization 2020a). The COVID-19 pandemic swamped the globe with fatalities, fear and uncertainties that persist to this day. It has changed the way people live in unprecedented times. In Singapore, as of 7 July 2020, a total of 45,140 COVID-19 cases with 26 deaths (Ministry of Health 2020) were reported. The COVID-19 virus, with a mode of transmission not entirely known and an unknown incubation period, poses a considerable threat for people who dwell in enclosed places. The infection risk for COVID-19 in an inpatient psychiatric ward, not surprisingly, can be higher than that of one in a general medical hospital due to the ward's living arrangements and the nature of coronavirus transmission. Worldwide, the COVID-19 outbreak was reported in several psychiatric hospitals (Ramgopal 2020; Yao et al. 2020 ). The first COVID-19 positive case reported in Singapore's tertiary psychiatric hospital was on 28 April 2020, at the Institute of Mental Health (IMH). The infection did not spread beyond a cluster of four patients, fortunately (Institute of Mental Health 2020). An immediate effort to mitigate the situation to prevent more patients from being infected was launched at the institutional and ministerial levels.

As part of the healthcare team, nurses work tirelessly and play an essential role in fighting this battle. This paper records nurses' experience in an inpatient psychiatric ward during the COVID-19 outbreak and discusses strategies deployed to overcome the challenges faced during this unprecedented time. The aim of this study was to understand nurses' responses to COVID-19 and identify their uptake of changes in the procedure required for the management of COVID-19 in an inpatient psychiatric ward.

Initiatives were introduced in response to the pandemic at the institution and national level, including the Ministry of Health Advisory and hospital updates of policies. These updates were disseminated to the ground daily via E-mail, workplace Facebook and the intranet. Strategies including minimizing staff contact during meal times (only one staff was allowed to be at the pantry without the mask), holding staff responsible for declaring their temperature twice daily, and performing check-in and out via the mobile apps for contact tracing when they need to move within the institution. As a safety measure, staff are not allowed to report to work if they have any signs or symptoms of upper respiratory tract infection (URTI), and they are required to seek medical treatment immediately. To prevent cross-infection, staff and patients remain in their respective wards, with adjustment to staffing in the multidisciplinary team to segregate the inpatient team from the outpatient team. Some doctors, all the case managers, psychologists and social workers from the team were removed from the ward setting to stay in the outpatient setting to prevent cross-infection. Multidisciplinary team members were encouraged to see patients via Zoom video conferencing and conducted family sessions via Teleconsult or Zoom video conferencing. Other policies on admission workflow, transferring of patients to a general hospital for medical treatment, the requirement for swabs on day zero and day five after admission for inpatients, segregation of 'high-risk' patients (e.g. patients from other institutional care) by temporarily placing them in a designated ward while pending swab test results, have been reviewed continuously and fine-tuned based on the changing infection level status.

For the psychiatric ward, in which few patients were tested positive, the following strategies were implemented. Firstly, nursing leaders (nurse manager and nurse clinician who are registered nurses taking the leadership role) ensured that personal protective equipment (PPE) items were sufficient and topped up immediately, clear infection control instructions were listed and monitored, and nurses were encouraged to shower after duty. To minimize contact with staff outside the ward, food and drinks were ordered and delivered to nurses' dining areas, with more resting areas allocated for nurses to have their meals to promote adequate rest. In addition, the hospital offered single room hotel for a short stay to nurses who were concerned with cross-infecting their family members.

Secondly, additional nurses were deployed to the ward for short-term relief to reduce nurses' burden and anxiety. Roster planners ensured a good mixture of different grades and genders in every shift, and all non-urgent activities were suspended. Besides, the introduction of flexible working hours, without compromising patients' care and others' safety, was helpful for nurses. Nurses were allowed to utilize hospitalization leave for URTI symptoms instead of having to worry about depleting their 14 days of medical leave entitlement and paid annual leave.

Thirdly, regular updates from nursing leaders about the ward situation and other contingency plans helped to alleviate nurses' worries. Useful and timely information related to COVID-19, provided by experts, was disseminated to nurses via Zoom meetings, to offer much assurance to most nurses. The psychology department set up a Staff Wellness Group to offer psychological support to any nurse in need. Self-encouraging notes and video on stress-coping tips were shared on the hospital intranet. Nursing leaders conveyed their appreciation in small ways, such as buying staff meals and verbally thanking staff, to show nurses that their contribution is valued.

Written feedback was collected to understand nurses' responses and identify their uptake of changes in procedure following the first COVID-19 outbreak in the ward. Prior approval was obtained from the hospital department of nursing before collecting the feedback from ward nurses. A written feedback form developed by authors was utilized in the ward where the COVID-19 outbreak occurred, two months after the implemented changes. All the nurses of the ward were briefed face-to-face and invited to fill up the free text feedback form, of which eighteen out of the 25 nurses responded. The written feedback was done voluntarily and anonymously, with the forms placed in a sealed box located in the nurses' office. No general information about the nurses was collected, to maintain anonymity, given the small sample size. Any identifying information provided by nurses from the feedback form was separated and modified to ensure confidentially. The feedback form contained the following free text questions which were developed based on study aims: 1. Could you please share your personal experiences/challenges faced during the outbreak? 2. What is your view with regards to policies and strategies deployed to manage the pandemic? 3. What is your view of the effectiveness of leadership of nursing leaders at different levels of hospital management?

The nurses' feedback captured in the feedback forms was manually analysed by two authors independently, feedback was categorized according to the question given, common themes extracted by each author without any predetermining concept or ideas were discussed and merged. The findings were summarized to make it more concise but without changing the original meaning.

The analysis of the survey data led to four main themes. The following common themes were derived from the survey: 'I felt overwhelming, worried about my family's safety, not sure how many patients would be affected', 'patient care was definitely being affected, especially therapeutic communication', 'If we had failed to adhere to hospital infection control measures and policies, the situation might have been a lot worse', and 'the urgent response by nursing leaders and hospital management was quick and efficient, we were well supported'.

A recent study showed that nurses are particularly vulnerable to suffering from symptoms of depression, anxiety and insomnia, while they care for patients suspected or confirmed to have COVID-19 (Lai et al. 2020 ). In the psychiatric ward where the first case of COVID-19 was detected, nurses were shocked, and more so after they learned that several other patients were tested positive for COVID-19 in the same ward. One nurse shared that 'I felt overwhelmed when we first found out and transferred vulnerable patients to isolation ward overnight'. Intense anxiety crept in during the initial part of the experience, largely due to the uncertainty regarding the number of patients or nurses being infected. Nurses who indicated no prior experience in nursing patients in a pandemic situation, such as severe acute respiratory syndrome (SARS) in 2003, expressed their lack of confidence in managing COVID-19 situations, 'Hectic and overwhelming as some of us have not had any experience with this kind of situation before and we do not know what to do'. A few nurses started to worry about their safety after they realized that they had long exposure time with COVID-19 positive patients. The concern of being infected and unknowingly spreading an infection to their family members was legitimate and invoked a great sense of helplessness. Some nurses imposed self-restrictions by confining themselves to a room after work to reduce the probability of cross-infection. While coping with uncertainty, they had to deal with the loneliness of being isolated and the feeling guilty for not being able to care for or spend time with their family members, 'I cannot go anywhere except the hotel room, not sure if my wife will be able to manage two children alone'.

Feelings of isolation intensified, as movement across wards or other hospital areas was curbed unless deemed necessary. One nurse stated that 'we were disconnected from the hospital, I got to see no one except our own ward staff, it was just us'. During mealtimes, only one nurse is allowed to be in the common tearoom, and mealtimes have to be shortened to ensure that all nurses were allocated a slot. Nurses expressed dismay as the regular socialization and proper rest time was significantly reduced to adhere to infection control measures.

Besides mental stress, nurses also experienced tremendous physical strain due to increased workload and physical exhaustion (Pappa et al. 2020 ). As the current psychiatric ward was not equipped to care for the suspected or confirmed COVID-19 patients, nurses in the psychiatric ward needed to transfer all suspected cases to the medical ward and receive the patients back once they were tested negative, 'I felt that we have spent much time on transferring patients, it was just too frequent'. Frequent patient transfers between psychiatric and medical wards increased nurses' workload as both wards were located at different blocks. It took 15-20 min for two nurses to send or fetch patients from the medical ward. The 5-day compulsory sick leave for staff with any upper respiratory tract infection (URTI) symptoms, while serving its function as a quarantine and safety measure, caused further strain on the nursing team, having to share the additional workload when nurse to patient ratio decreased. Nurses also reported they found it challenging to perform electronic nursing documentation with full PPE, and they experienced breathlessness after a short conversation, after having to raise their voices to be heard with the N95 masks on.

In a psychiatric setting, therapeutic interaction between nurses and patients is essential. However, it posed great challenges for nurses to communicate effectively with patients in full PPE. 'It was almost impossible for the patient to hear me if I speak in a soft and emphatic tone from a distance with the donning of the N95 mask', 'some patients could not recognize me when I was under full PPE, they felt that we all looked the same, I think our connection with patients was affected'. Nurses also shared the challenge they faced while looking after patients who were still in an acute psychotic state, 'the difficulty in communication frustrated them, leading to undesirable behaviours such as spitting or being violent towards nurses'.

Personal hygiene and social distancing are the recommended essential measures to prevent transmission of COVID-19. However, nurses reported that despite their attempts to educate and urge the patients in the psychiatric ward to wear masks and maintain a safe distance, many did not adhere to these measures due to limited cognitive abilities to appreciate the risks. Nurses shared in the survey that 'patients continued to ambulate and interact without masks or wore the masks inappropriately, some patients insisted on lying on the floor or walking around barefooted despite multiple reminders from nurses'.

As part of the infection control measures to curb infection spread, the hospital introduced a no visitation policy in the ward. No family visitation or food delivery to the ward had led to increased tension between patient/family members and nurses, 'I could sense that patient's family members were feeling guilty, anxious and helpless as they could not see their loved-one face-to-face, sometime, they may just direct their emotion on us'.

Understandably, patients were likely to experience anger and frustration due to quarantine (Brooks et al. 2020) , and may perceive a higher level of distress due to the prolonged quarantine than that perceived by the general population (Iasevoli et al. 2020) , 'few patients asked me many times about their COVID-19 swab result though they have been informed that it was negative, some patients requested to perform extensive test to double confirm that they were not infected'.

Nurses' view towards policies and strategies deployed to manage the pandemic Overall, the survey showed that nurses were receptive, satisfied and confident of the hospital directives implemented during the outbreak. Nurses believed that policies were put in place to protect them and their patients, though they did cause certain restrictions. They were confident to pull through this difficult period with policies and strategies in place.

Nurses emphasized that nursing leaders at different levels of hospital management were important to allay their anxiety. One nurse shared that 'The nursing leaders have taken care of our well-being, all our requests were granted, from snacks ranging to additional air coolers to accommodation'. Another nurse felt that instructions from the ward Nurse Clinician were clear, transparent and updated. Nurses felt nursing leaders were 'very supportive, always checking up on us, making sure we are all fine and asked if we have any concerns to reach out to them'.

Nurses have always been the backbone of the healthcare system, and their roles in caring for and keeping patients safe is even more critical in times like this. Understanding nurses' responses to COVID-19 and how they identify their uptake of changes in the procedure required for the management of COVID-19 in an inpatient psychiatric ward is the initial step to ensure that nurses remain steadfast in their profession. Though public recognition may add value and purpose to the profession, the practical support from non-nursing colleagues and strong nursing leadership has proven imperative in the battle against the COVID-19 outbreak in the Institute of Mental Health, Singapore. A clear, transparent and timely communication helped offset nurses' fear and uncertainty (Rosa et al. 2020) . Maintaining sufficient resources and providing psychological support have been shown to have an effect on boosting nurses' confidence and stress-coping ability. Based on the survey, nurses reflected that ample support was rendered to reduce the physical burden and increase their psychological resilience despite the challenges faced. Nursing leaders played a significant role in supporting nurses to cope with challenges during this stressful period (Fernandez et al. 2020) . It is evident that nurses' efforts with nursing leaders' support, in addition to nurses' resilience, are attributed to the successful management of the COVID outbreak.

As nurses progressively equip themselves with the confidence and skills to manage the COVID-19 situation in the ward, nurses can intervene to enhance patients' care and awareness of national and global COVID-19 situations. As a usual way of communication is limited under full PPE, good nonverbal communication skills, such as maintaining attentive posture with good eye contact and showing interest in what the patient was sharing, can be useful ways to communicate with patients in the psychiatric ward. Nurses may consider using a gentler tone of voice to compensate for the rise in volume, with the aid of notebooks and small whiteboards, to improve communication. Nurses need to take active measures (e.g. frequent parameter monitoring, checking patients for symptoms, reminding patients to perform regular handwash/ hand rub, and regular use of hand rub and disinfectants) to detect any possible case and reduce the risk for transmission . Patients who cannot follow infection prevention measures are nursed in a separated area within the ward. Regular phone calls to family members and updates them on COVID-19 test results and the patient's condition by nurses will allay family's anxiety. Phone video calls or secured Zoom meetings can be offered to patients to keep in touch with family members. Nurses can create more individual sessions of activities and assign patients to a different ward location with necessary materials for self-recreational activities.

The COVID-19 pandemic highlighted the importance for psychiatric nurses to be well prepared to manage a sudden outbreak in the ward, apart from being familiar with providing psychiatric care. Nurses need to harness creativity and the human touch in creating more compelling services. Nurses' willingness to adjust to the reconfiguration of operations to accommodate to changes has shown to be crucial for the healthcare system to run effectively. When adequate support was rendered, nurses were able to overcome their fear and anxiety, took up new job scopes, and re-skilled for roles on the frontlines such as swabbing or re-deployed to assist in facilities. Good practices and policies established during this crisis should be developed and established on a permanent basis in nursing practice.

Prompt and effective policy-making at the national and institutional level can determine the outcome of nursing care in a pandemic in a psychiatric setting. Our experience suggests that policymakers at the national and institutional levels need to devise contingency plans in preparing for a massive pandemic in a psychiatric setting. Well-planned drills, training, and education protocol related to infection control should be in place to help nurses adjust smoothly during a pandemic.

Institutions need to consider implementing effective human resources management in the context of COVID-19, including looking into occupational health and safety, staff's morale and mental well-being, ensuring sufficient rest periods, and providing adequate and timely PPE. Organization-wide refresher training on infection prevention and control, clear guidelines to guide management, with an unambiguous delegation of tasks and decision-making roles, are to be promptly established to reduce confusion. As evident from the nurses' feedback, policy interventions at organizational and systemwide levels, targeting maintaining a manageable workload, and promoting leadership at multiple levels (World Health Organization 2020b), are important in overcoming challenges during the COVID-19 pandemic.

The experiences from ward nurses showed that it is possible to successfully manage COVID situations in an inpatient psychiatric setting with support from influential nursing leaders and pertinent strategies/policies. Nurses were presented with great challenges to meet infection control needs and the psychological well-being of patients, in addition to their concerns. However, nurses managed to pull through this challenging period with their professional dedication and nursing leaders' support.

Looking ahead, the COVID-19 pandemic may linger on for a while; the needs of nurses' and patients' mental health remain high. Nurses working in inpatient psychiatric ward will need to maintain a therapeutic and conducive environment to meet patients' mental health needs and aid their recovery while maintaining their resilience. It will be beneficial to learn from psychiatric nurses worldwide on how they react to meet the needs of psychiatric inpatients in this challenging time of the pandemic.

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I like to take this opportunity to show my gratitude to all the ward nurses for their dedication in caring for patients during this pandemic and their active participation in providing valuable feedback.