key: cord-0925896-9xod9okl authors: Riddell, Kathryn; Bignell, Laura; Bourne, Debra; Boyd, Leanne; Crowe, Shane; Cucanic, Sinéad; Flynn, Maria; Gillan, Kate; Heinjus, Denise; Mathieson, Jac; Nankervis, Katrina; Reed, Fiona; Townsend, Linda; Twomey, Bernadette; Weir‐Phyland, Janet; Bagot, Kathleen title: The context, contribution and consequences of addressing the COVID‐19 pandemic: A qualitative exploration of executive nurses' perspectives date: 2022-02-15 journal: J Adv Nurs DOI: 10.1111/jan.15186 sha: 04083d94fd060fce713a366e2c2f21f69ab61e56 doc_id: 925896 cord_uid: 9xod9okl AIMS: To explore (1) the context in which nursing executives were working, (2) nursing's contribution to the healthcare response and (3) the impact from delivering healthcare in response to the pandemic. DESIGN: Retrospective, constructivist qualitative study. METHODS: Individual interviews using a semi‐structured interview guide were conducted between 12 February and 29 March 2021. Participants were purposively sampled from the Victorian Metropolitan Executive Directors of Nursing and Midwifery Group, based in Melbourne, Victoria the epi‐centre of COVID‐19 in Australia during 2020. All members were invited; 14/16 executive‐level nurse leaders were participated. Individual interviews were recorded with participant consent, transcribed and analysed using thematic analysis. RESULTS: Four inter‐related themes (with sub‐themes) were identified: (1) rapid, relentless action required (preparation insufficient, extensive information and communication flow, expanded working relationships, constant change, organizational barriers removed); (2) multi‐faceted contribution (leadership activities, flexible work approach, knowledge development and dissemination, new models of care, workforce numbers); (3) unintended consequences (negative experiences, mix of emotions, difficult conditions, negative outcomes for executives and workforce) and (4) silver linings (expanded ways of working, new opportunities, strengthened clinical practice, deepened working relationships). CONCLUSION: Responding to the COIVD‐19 health crisis required substantial effort, but historical and industrial limits on nursing practice were removed. With minimal information and constantly changing circumstances, nursing executives spearheaded change with leadership skills including a flexible approach, courageous decision‐making and taking calculated risks. Opportunities for innovative work practices were taken, with nursing leading policy development and delivery of care models in new and established healthcare settings, supporting patient and staff safety. IMPACT: Nursing comprises the majority of the healthcare workforce, placing executive nurse leaders in a key role for healthcare responses to the COVID‐19 pandemic. Nursing's contribution was multi‐faceted, and advantages gained for nursing practice must be maintained and leveraged. Recommendations for how nursing can contribute to current and future widespread health emergencies are provided. With over 230 million cases and almost 5 million deaths worldwide (as at 4 October 2021), the COVID-19 pandemic has presented a significant challenge to healthcare systems, with substantial risks for the healthcare workforce Quigley et al., 2021) . For example, in the first 6 months of the pandemic, results indicated that Australian healthcare workers were more than 2.5 times more likely to contract COVID-19 than community members (Quigley et al., 2021) . There are almost 28 million nursing personnel globally (World Health Organization, 2020) , comprising the largest proportion of the health workforce (59%), with nurses likely the first clinical contact for those presenting to health services (World Health Organization, 2020) and making up to 90% of patient/clinician contacts (Crisp et al., 2018) . As such, the nursing workforce is critical to the healthcare system response (Halcomb et al., 2020) , placing executive nurse leaders in a key role responding to the pandemic. However, little is known about their experiences during COVID-19 (Hølge-Hazelton et al., 2021) . In Australia, initial modelling, Government responses and recommendations focused on nurse staffing numbers for intensive care unit (ICU) beds (Australian Government, 23 March 2020; Litton et al., 2020; Marshall et al., 2020) . For example, initial estimates indicated a 269% increase in registered ICU nurses could be required (Litton et al., 2020 ) and a call for former ICU nurses was made (Australian Government, 23 March 2020) . However, nurse leaders played a critical role during the previous coronavirus outbreaks with severe acute respiratory syndrome (SARS) crisis, demonstrating significant crisis management expertise (e.g. Tseng et al., 2005 ). An early exploration (April 2020) of public health nursing staff needs during COVID-19 illustrated the broad impact on nursing activities (Halcomb et al., 2020) . Survey results from 637 Australian-based public health nurses employed in various settings (e.g. general practice, community health, schools/universities, Aboriginal health services, etc.) identified seven key areas where support was required. Key areas included access to personal protective equipment (PPE), communication (e.g. protocolized care, delivery of information, professional education), service funding (e.g. nurse telehealth, nurse billing) and industrial issues (e.g. job security, leave, etc) (Halcomb et al., 2020) . Meeting these diverse needs in challenging and stressful circumstances, and the reliance on nursing to deliver care, requires substantial management. Some early investigations into nurse leaders' experiences are available from the United States of America (USA) (Aquilia et al., 2020; Joslin & Joslin, 2020) . For example, nurse leaders (n = 1824) completed an online survey in July 2020 with the top challenges for addressing COVID-19 identified. These included managing with no established procedures, surge workforce required, staff well-being concerns and access to equipment including PPE (Joslin & Joslin, 2020) . Leaders from a range of different settings were included, and results were combined across leadership roles; that is, Chief Nursing Officer/Executive (approximately 20% of sample) alongside Directors and Managers. This quantitative approach precluded a nuanced understanding of their experience. Another article (sample size and timing not reported) presented a qualitative narrative on nurse leaders' experiences, reporting on some of their contributions and challenges during COVID-19 (Aquilia et al., 2020) . The authors highlighted the significance of decision-making and adapting with limited information and changing circumstances, alongside the importance of staff well-being and ensuring highquality patient and family experiences. These results illustrate the breadth of nursing's role, beyond the initial expected focus of providing staffing for ICU wards. While providing some initial insights into nurse leaders' experiences from early in the pandemic, detailed research methodologies were not presented and participants reflected broad nursing management roles. A rigorous qualitative research design using individual interviews with nurse executives is needed to provide a robust understanding of the 16 Data Drawer Consulting, Sandringham, Victoria, Australia information and constantly changing circumstances, nursing executives spearheaded change with leadership skills including a flexible approach, courageous decisionmaking and taking calculated risks. Opportunities for innovative work practices were taken, with nursing leading policy development and delivery of care models in new and established healthcare settings, supporting patient and staff safety. Impact: Nursing comprises the majority of the healthcare workforce, placing executive nurse leaders in a key role for healthcare responses to the COVID-19 pandemic. Nursing's contribution was multi-faceted, and advantages gained for nursing practice must be maintained and leveraged. Recommendations for how nursing can contribute to current and future widespread health emergencies are provided. COVID-19, nurses' role, nursing, nursing models, qualitative research This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Inkind support from each author's hospital. most senior nurse hospital leaders' experiences responding to the pandemic. This information will provide important insights to those responsible for preparing for or managing in similar circumstances. The aim of the current study was to understand the nursing response to the COVID-19 pandemic in Melbourne, Australia from the perspective of nursing executives. Specifically, we will explore (1) the context in which nursing executives were working, (2) nursing's contribution to the healthcare response and (3) the impact from delivering healthcare services in response to the pandemic. We used a qualitative, retrospective research design, with a constructivist approach. In-depth individual interviews were conducted using a semi-structured interview guide. During 2020, Victoria became the epi-centre of COVID-19 with 73% (20,345/27,923) of Australia's COVID cases, 88% (19,360/22,092) of locally acquired cases, and 90% (820/908) of COVID deaths (2 December 2020) (Australian Government Department of Health, 2020). Victoria was declared a State of Emergency (16 March 2020) with two main waves and associated lockdowns experienced (see Figure 1 for timeline). Health services within Victoria are Government funded and function independently of one another. Melbourne is the capital city of the south-eastern state of Victoria, Australia; the greater Melbourne area has an estimated resident population of 5.2 million (Australian Bureau of Statistics, 2021), covering a geographical area of almost 10,000 square kilometres. needed (probes such as 'tell me more about that' were also used) covering three key areas: ascertaining the contribution of nursing to the response (e.g. system-, organizational-or individual-level contributions), the resources required for the associated changes (e.g. staffing, PPE, supplies) and the impact on nursing (e.g. new standards of practice, varying models of care, workforce). Participants were also asked about ongoing concerns and any benefits identified from the nursing practice response or pandemic. Two pilot interviews were undertaken to test content and timing. Interviews were recorded with participant consent, transcribed verbatim and anonymised. Reflexive thematic analysis (Braun & Clarke, 2012 , 2021 was conducted inductively (no a priori framework) by one researcher (K.B.). Analysis was undertaken through six consecutive stages: stage 1 required data familiarization through iterative reading of transcripts, in stage 2 initial categories were identified through coding from line-by-line analysis and stage 3 was grouping categories, including hierarchical relationships between codes. Stage 4 was identifying and refining key themes and sub-themes, with stage 5 involving defining and naming of themes. Stage 6 included review and endorsement by all authors during write-up. NVivo (v12) software was used for stages 1-3, and a virtual whiteboard (www.miro.com) for stages 4-5 to facilitate analysis. The interviewer had no previous relationships with participants, but was experienced in conducting qualitative and quantitative research with healthcare clinicians across multiple health ser- There were four main themes identified: (1) rapid, relentless, around the clock action; (2) nursing's multifaceted contribution; (3) unintended consequences and (4) silver linings (Table 1) . While themes are presented separately, they are overlapping and inter-related. In text below, themes are bold and underlined, and sub-themes are italicized and underlined. All participants noted that constant engagement in their roles was required. Five sub-themes underpinned the relentless action: (i) insufficient preparation, (ii), extensive information and communication, (iii) expanded working relationships, (iv) constant change and (v) the removal of barriers. While some participants indicated having experience in similar health crises, and hospitals had pandemic-specific and emergency BOX . What enablers were put in place for these changes to take place? 10. What barriers were removed for these changes to take place? Prompts for both a. Formal or informal processes? How were these resources sourced? b. Working with others? 11. Are any of these identified changes still in place? Are they considered interim or permanent? 12. Can you describe the impact of addressing COVID on nursing practice? Prompts a. Professional autonomy; status, profile; scope of practice; staff retention b. Workspace c. Experiences, for example, physical, including personnel testing positive for COVID-19 or emotional, including for personnel working outside usual setting plans, the preparation for COVID-19 was mostly insufficient for the reality. One participant noted: We had to dust off an old pandemic plan that was just threadbare. There was nothing of much value in it, and it really didn't address anything on this sort of scale or with this sort of level of transmission. So we were totally unprepared for what was coming. … so there were multiple sources of information, some of them more reliable than others, that was just leading to great confusion to be quite honest. Keeping staff informed safely required changing to multi-modal methods including predominantly virtual meetings (via Microsoft Teams) with face-to-face options not often available. Working relationships were extensive and mostly supportive. Executive and Incident Command in their healthcare service and externally in multi-site groups and government oversight. Internal hospital working relationships included executive teams and management, and members of nursing, medical, allied health and support services. We still meet as an executive team daily. One of the things that we received a lot of really positive 13. Are there any current concerns associated with the pandemic? a. What is your greatest concern currently about the pandemic? 14. What would you want someone in your position know when addressing the pandemic? For example, someone in another state of Australia preparing for an outbreak? 15. Were there any beneficial outcomes from addressing the pandemic? 16. What is your/nursing proudest achievement from addressing the pandemic? Conclude 17 . Is there anything else you would like to add? 18. Wrap up a. Would you like to receive a copy of the transcript for review prior to analysis? b. All quotes will be deidentified; that is, attributed to, for example, EDON 1, and personal details (e.g. years of experience) used only when not able to be identified Thank you very much for time and input. Will be helpful to understand current and future aspects of addressing pandemic from nursing perspective. feedback for was that people said they really appreciated the rapid decision-making that meeting daily provided and people didn't feel they were having to wait. It was changing on a daily basis, sometimes an hourly or two-hourly basis. (Participant 013) New geographically based hubs of multiple health services (now called Health Service Partnerships) were implemented to organize and deliver care. These hubs required governance infrastructure, working relationships and protocols to be developed, operationalized and established, in addition to those underway within each health service. Support to address and undertake these changes was predominantly from the removal of organizational barriers. Governance of changes by multiple committees was reduced, business cases or change impact analyses were not required to the same degree as pre-COVID-19, and expedited processes for financial approvals were established. Normally we're very consultative and to get policy changes takes probably about three months for them to go through all the various committees. It was just approved through incident command and put up that day. There were multiple nurse-led initiatives such as pilots and programmes for equipment fit testing and community watch. In some cases, a whole team or ward needed to be furloughed due to a COVID-19 case contact/outbreak, and replacement workforce members were required to be sourced, trained, deployed and supported. These activities were not identified prior to the pandemic, but were negotiated and undertaken in real time. I can remember on a Friday night we were notified that we had … one staff -two staff and then another four staff within a matter of six hours COVID positive and then we had to shut our ED down which was significant. … We didn't shut it down completely; we did a whole new model of care but we had to furlough 500 staff from that ED at that time. (Participant 001) A number of unintended consequences were identified for the nurse leaders, extending to the nursing workforce. Sub-themes included (i) nurse leaders' personal experience, (ii) a mix of emotions while managing a nursing workforce with (iii) difficult working conditions, leading to both (iv) short-and long-term consequences, with some (iv) new opportunities. Overall, participants described the difficult experience of addressing the pandemic as "super challenging" (Participant 003) and Some participants also noted that they personally experienced the policies they were developing and implementing, including being unable to visit a hospitalized family member. There were some positive aspects of the experience, including all reporting an immense pride in the nursing workforce, the scope and scale of the contribution that nursing made, and knowing that the efforts of nursing had really "made a difference" (Participant 005), with one saying they were "exceptionally proud of the profession" (Participant 001 In particular, many systems within aged care facilities were improved and retained, including protocols, governance and clinical care established. Some new opportunities were described, particularly leadership opportunities became available. One participant noted that a nurse had indicated that the work they were involved in was the "highlight of her career" (Participant 011), others noted that it was "empowering" (Participants 008 and 013). It's helped them [nurse managers] also find more of their voice and their power to influence and drive changes and not sweat the small stuff and just get on. Things that we've been challenged with for many years and we've just sort of crashed through a lot of that now. (Participant 002) I think our line managers have really been able to take leadership learning and really apply them. So I think that they are far better leaders than what they were at the start of this and we're absolutely seeing them wanting to be more autonomous and that's a great thing. So I think that that's been a positive out of it. (Participant 008) Student nurses had an expanded role, described as "scary but rewarding" (Participant 011). Another silver lining was the deepening of work relationships, including expanded collegiate working relationships and professional connections, extended respect for others' work areas particularly for support services such as cleaning and catering, with many participants noted a stronger connection with team members. Nurses might be at the forefront of it, we're also the largest workforce but nobody does this alone. Never before have cleaners been more important to be alongside our professions. The expertise of our medical staff, the willingness of our allied health staff to take on completely different roles. They were so important in our response as well. (Participant 011) Some noted that the value of nursing by the community increased. To Support from working relationships with government and union was important, but while some jurisdictional barriers were actively removed, others remained and governmental directives were delayed or contradictory information received. As such, nursing executives had to spearhead change, and be decisive without a solid evidence base. In the face of such uncertainty, personal and professional qualities merged, with leadership comprising courageous decision-making, taking calculated risks and being agile and constantly re-inventing clinical, management and communication practices (Aquilia et al., 2020) . Nurse leaders in the United States have also reported significant decision-making with limited information (Aquilia et al., 2020) , with another reporting nurse leaders demonstrating significant adaptability and innovation while overworked and stressed (Freitas et al., 2021) . Capitalizing on nurse leadership is one of the International Council of Nurses' key priorities to beat COVID-19 (International Council of Nurses, 2020). Drawing on their specialist expertise and experience, nurse executives in the current study were leading changes and improvements, re-engineering the workforce and physical environment, and ensuring that barriers did not get in the way of what was required to be done. Recent research in one hospital (n = 6 nurse leaders, Brazil) also reported substantial workforce and environmental changes undertaken by nursing (Freitas et al., 2021) . For our participants, these changes occurred internally and externally to the home hospital, including working with other health services (as part of a hub) further extending their work environments, working remotely from the hospital or team members. Without established procedures (Joslin & Joslin, 2020) , nurse executives were trailblazers ensuring that multiple new models of care were developed, resourced and implemented to meet patient and staff needs safely. As reported elsewhere (Kerrissey & Singer, 2020) , identifying someone in charge of the response proved difficult at times, and similar to that in the United States (Stucky et al., 2020) , the pandemic exposed limitations in the local healthcare system, particularly in aged care (Royal Commission into Aged Care Quality and Safety, 2020), with increased risks for those working there . One local example had nursing lead and operate all aspects of a number of aged care facilities, well beyond usual practice and with limited facility staff. A number of innovations were reported by participants, including new models of care, novel communication practices, and input and leadership from unexpected staff. International work has outlined how the pandemic has provided a unique circumstance for nursing practice reforms, including change in practice (Stucky et al., 2020) . For example, a number of legislative changes were made within the United States to extend the role of nurse practitioners' practice. For many, the use of undergraduate nurses in the workforce was an innovative model, but not without risk. However, reports of adapting well to registered roles suggest for many this was a successful approach. In a content analysis of USA graduating nurses' (n = 84) assessment of personal practice within COVID-19, the majority indicated they were willing to care for COVID-19 patients but robust PPE was required (Lancaster et al., 2021) . Such innovations were supported through funding available to address COVID-19, cross-functional teams and a shared purpose, and should not be rolled back. Others have also identified that benefits gained though addressing the pandemic should be maintained (Palese et al., 2021) . (James et al., 2021) . Participants reported ethical dilemmas (e.g. which clinical trials to continue, which to cease; inadequate PPE available for staff, asking more from an exhausted workforce), as reported elsewhere (Aquilia et al., 2020) . Moral distress has been previously associated with absences and turnover (Gaudine & Thorne, 2012) . Conflicting obligations have also been previously reported for nursing (Lancaster et al., 2021) with low resilience and job satisfaction associated with executive nurse turnover (Bernard, 2021) . Nurses' willingness to continue to work, working face-to-face with other staff and patients at their home hospital or in other settings were commonly reported, with some hesitancy revealed to move from non-COVID to COVID settings by a few participants. Difficulties of working included safety/risk concerns to self and their families, along with the discomfort of working in PPE have been reported by the ANMF (Adelson et al., 2021) and elsewhere (Lancaster et al., 2021) . In their survey of 32,174 nurses, the American Nursing Association reported that 87% were 'very' or 'somewhat' afraid to go to work (American Nursing Association, 2020). Results also indicated that 68% of nurses were worried about staff shortages (American Nursing Association, 2020). In their survey (n = 13,410, 85% nurses, midwives or personal care workers), the ANMF reported high levels of emotional exhaustion for those working in residential aged care facilities and hospitals (Adelson et al., 2021) . Continuing to provide care despite risks has previously been reported by Australian healthcare workers as a professional obligation (Seale et al., 2009 ). The capacity and resilience of the workforce, both at bedside and executive levels, has been depleted (Galanis et al., 2021) . Higher nursing workload has been reported internationally (Hoogendoorn et al., 2021) , along with behavioural and psychological impacts (American Nurses Foundation, 2020). A recent scoping review of healthcare workers risks during COVID-19 found that nurses had the worst health outcomes (Franklin & Gkiouleka, 2021 tive ways of working) need to be addressed (Adelson et al., 2021) . Based on the contributions, negative consequences and potential risks identified in our study, we provide our top five recommendations for addressing widespread health emergencies (Table 2) . The current study has a number of strengths including the robust qualitative methodology using a constructivist approach. This design allowed an in-depth exploration and presentation of executive nurses' insights and experiences. Nurse executives were from multiple health services at the epicentre of the COVID-19 pandemic in a large metropolitan city. Many of our insights are relevant to global nursing policy and practice. Limitations, however, need to be considered. This study is based on a small, pragmatic sample, and to maintain anonymity we were unable to report on demographics. This gap meant we could not speak to inclusive (or not) representation across health services for nursing at the executive level. However, participants represented all of the nursing executives actively responding to COVID-19 for the major metropolitan hospitals in a large metropolitan city of Australia during 2020. This study focused on the experiences and perspectives of the executive level. Future research is required to capture that of the bedside nursing workforce, and that of Nurse Unit Managers. It is to be noted that as the work was initiated and conceptualized by the group, many of the authors acted as participants as well. The scope and scale of participant reports were extensive, reflecting the range of their experiences during 2020. While many nursing executives shared experiences, some had unique role/s and many areas warrant a detailed exploration outside the scope of this work, including how nursing led the aged care response, multi-disciplinary education in infection control or transitioning workforce across specialities and/ or unique settings. In the first year of responding to the COVID-19 pandemic, nurse executives detailed a complex context of multiple stakeholders, extensive information and constant changes. Significant leadership qualities consistent with values-based leadership models, including being proactive, rapid decision-making, flexible work approach and agile change management were required to identify and mobilize resources and infrastructure to design and implement acute, community and public health policies, and develop and deliver protocols for safe practice. These results illustrate the breadth and impact of the experience of nursing responding to the COVID-19 pandemic across a range of healthcare settings. During the International Year of the Nurse and the Midwife, nursing went beyond being key stakeholders to proactively leading the development and delivery of health services and community, ensuring continuity of care to patients. For the sustainability of nursing, nurse executives and health services, attention must be paid to addressing workforce exhaustion and trauma. As outlined in the recommendations, maintaining the opportunity to work to the full scope of nursing practice should continue and be leveraged to emphasize nursing's contribution at all times in healthcare. The Midwifery Group initiated and members were participants in this re- search. An experienced researcher independent from the group was funded to conduct all aspects of the research. All authors have agreed on the final version and meet at least one of the following criteria: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content. supervision. The St Vincent's Hospital Human Research Ethics Committee approved the study (72529, LRR 001/21; 22 January 2021). Participation was voluntary and confidential from the group membership. Verbal consent was obtained from participants prior to the interview recording commencing. Illustrative quotes are deidentified. The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15186. The data are not publicly available due to privacy or ethical restrictions. Kathleen Bagot https://orcid.org/0000-0003-2895-4327 COVID-19 and workforce wellbeing: A survey of the Australian nursing, midwifery, and care worker workforce. A report prepared for the Australian Nursing and Midwifery Federation Triple impact: How developing nursing will improve health, promote gender equality and support economic growth what-you-need-to-know/ment a l-healt h-and-wellb eingsurve y/ American Nursing Association Regional population 2019-20 financial year austr alian -healt h-secto r-emerg encyrespo nse-plan-for-novel -coron aviru s-covid -19-short -form Australian Government Department of Health The relationships between resilience, job satisfaction, and anticipated turnover in CNOs Thematic analysis Reflecting on reflexive thematic analysis One size fits all? What counts as quality practice in (reflexive) thematic analysis? Nursing & midwifery: The key to the rapid and cost effective expansion of high quality universal healthcare world innovation summit for health Who speaks for nursing? COVID-19 highlighting gaps in leadership A scoping review of psychosocial risks to health workers during the COVID-19 pandemic Nurse Leaders' challenges fighting the COVID-19 pandemic: A qualitative study Nurses' burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta-analysis Nurses' ethical conflict with hospitals: A longitudinal study of outcomes The support needs of Australian primary health care nurses during the COVID-19 pandemic Health professional frontline Leaders' experiences during the COVID-19 pandemic: A crosssectional study Agents of change: The story of the nursing now campaign The impact of COVID-19 on nursing workload and planning of nursing staff on the intensive care: A prospective descriptive multicenter study ICN highlights top priorities to beat COVID-19 Nursing and values-based leadership: A literature review Nursing leadership COVID-19 insight survey: Key concerns, primary challenges, and expectations for the future Leading frontline COVID-19 teams: Research-informed strategies. NEJM Catalyst, Innovations in Care Delivery A qualitative examination of graduating nurses' response to the COVID-19 pandemic Surge capacity of intensive care units in case of acute increase in demand caused by COVID-19 in Australia A critical care pandemic staffing framework in Australia Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. The Lancet Public Health Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: A mixed methods systematic review Estimating the burden of COVID-19 on the Australian healthcare workers and health system Will they just pack up and leave?" -Attitudes and intended behaviour of hospital health care workers during an influenza pandemic Clinical leadership and nursing explored: A literature search COVID 19: An unprecedented opportunity for nurse practitioners to reform healthcare and advocate for permanent full practice authority The effect of mindfulness training on burnout syndrome in nursing: A systematic review and metaanalysis Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups SARS: Key factors in crisis management Victorian healthcare worker (clinical and non-clinical) COVID-19 data State of the World's nursing: Investing in education, jobs and leadership The context, contribution and consequences of addressing the COVID-19 pandemic: A qualitative exploration of executive nurses' perspectives JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN: • High-impact forum: the world's most cited nursing journal, with an Impact Factor of 2.561 -ranked 6/123 in the • Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide Positive publishing experience: rapid double-blind peer review with constructive feedback • Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency's preferred archive