key: cord-1035911-jef97r6r authors: Marshall, Victoria K.; Chavez, Melody; Mason, Tina M.; Martinez‐Tyson, Dinorah title: Emergency preparedness during the COVID‐19 pandemic: Perceptions of oncology professionals and implications for nursing management from a qualitative study date: 2021-07-11 journal: J Nurs Manag DOI: 10.1111/jonm.13399 sha: 260f86a718d39baca46bf5a1e7f31669a641ebed doc_id: 1035911 cord_uid: jef97r6r AIM: To explore oncology health care professionals' perceptions of the COVID‐19 pandemic response. BACKGROUND: The pandemic has created health care delivery challenges globally and many countries have exhibited low readiness and emergency preparedness. METHODS: A descriptive design using a qualitative approach was employed. Semi‐structured interviews, which were completed via telephone, were audio recorded and transcribed verbatim. A thematic analysis was conducted. RESULTS: Participants (N = 30) were mostly registered nurses (70%). Three themes emerged: (1) ability to adapt and operationalize disaster planning, training and restructure nursing models (subtheme: reactive vs. proactive approach to emergency preparedness); (2) COVID‐19 task forces and professional organisations were critical for valid information surrounding the pandemic; and (3) recommendations for emergency preparedness/planning for future pandemics. CONCLUSION: Oncology organisations adapted during the pandemic, but policies and procedures were perceived as reactive and not proactive. Recommendations for planning for future pandemics included (1) adequate personal protective equipment, (2) developing cancer‐specific guidelines/algorithms and (3) telehealth training related to billing/reimbursement. Professional organisations were reliable resources of information during the pandemic, but oncology professionals ultimately trusted employers and administration to distribute information needed for safe patient care. IMPLICATIONS FOR NURSING MANAGEMENT: Frontline nurses should hold positions on task forces to develop future emergency preparedness. The novel coronavirus pandemic has plagued over 123 million individuals worldwide, with over 2.7 million deaths reported as of March 2021 (World Health Organization, 2021) . Many countries, including the United States, have exhibited low readiness and emergency preparedness to respond to a public health emergency (Jacobsen, 2020) . COVID-19 has resulted in the inability to effectively care for the surge of patients seeking care at hospitals, handle surveillance and laboratory influxes, safeguard frontline health care workers and maintain adequate communication of changing pandemic-related policies and procedures (Jacobsen, 2020) . Such pitfalls underscore the importance of necessary, sustained emergency preparedness interventions and ongoing committees to ensure that health care organisations are better prepared for future pandemics or other national emergencies. In the early phases of the pandemic, there was limited research specific to emergency preparedness for patients with cancer during a global pandemic (Al-Shamsi et al., 2020) . This is especially significant given that patients with cancer undergoing active cancer treatment are already a vulnerable and immunocompromised population (Bansal & Ghafur, 2020; Leung et al., 2020; Sahar et al., 2020) and are known to have worse outcomes related to COVID-19 including higher risk for hospitalizations, admissions to intensive care units and the need for mechanical ventilation (Huang et al., 2020; Jung et al., 2020; Liang et al., 2020; Papautsky & Hamlish, 2020) . This population is at risk for increased morbidity due to the inability to treat cancer as is typically customary such as postponed or cancelled cancer treatments and related appointments (Papautsky & Hamlish, 2020; Salako et al., 2020) . Oncology professionals were faced with the dilemma of protecting their vulnerable patient population from the COVID-19 virus and providing safe and timely cancer care. In a cross-sectional study, Jazieh et al. (2020) identified that 88% of 356 cancer centres from 54 countries across six continents around the world faced challenges providing the same level of cancer care prior to the pandemic. Participants in oncology care noted similar challenges in the wake of the pandemic compared with health care workers in the general medical fields including an overwhelmed health system, lack of personal protective equipment (PPE), staff shortages and limited access to medications (Jazieh et al., 2020) . Interruptions to health care, including cancer care, were reported to affect nearly 80% of patients (Jazieh et al., 2020) . The World Health Organization has provided recommendations for oncology care during the COVID-19 pandemic. Such guidelines include developing strategies to reduce in-person clinical visits and implement remote care, utilizing existing digital platforms to control COVID-19 exposure, continuing to administer emergency/essential services and practicing safely according to established global public health standards (Salako et al., 2020) . Emerging evidence also reveals the impact of the pandemic on frontline health care workers, including inadequate knowledge and skills related to the pandemic response, lack of PPE, lack of decision rights related to workflow, limited staffing and allocation of staff resources, and lack of communication between hospital administration and frontline workers on evolving changes (Sanford & Prewitt, 2021; Veenema et al., 2020) . In a recent survey, it was identified that 87% of nurses feared going to work, 36% reported lack of adequate PPE while caring for an infectious patient and only 11% felt well-prepared to take care of COVID-19 positive patients (American Nurses Association, 2020a). In addition, the realities of COVID-19 cancer care have exacerbated oncology nurse distress due to numerous practice changes, intensified burnout, compassion fatigue and personal challenges (e.g., family stressors) produced by the pandemic (Barello et al., 2020; Segelov et al., 2020) . More than a year into the pandemic, numerous analyses and recommendations have since been published for oncology emergency preparedness in response to the pandemic (Jazieh et al., 2020; Richards et al., 2020) . To date, however, there has been no qualitative analysis of emergency preparedness of oncology health care providers. This study aims to fill that gap by eliciting the experiences of frontline oncology professionals during the pandemic. The purpose of this study was to explore oncology health care professionals' perceptions of the response to the COVID-19 pandemic and emergency preparedness of their employment organisations. A descriptive design using a qualitative approach was employed. Applied thematic analysis (Guest et al., 2011) Oncology health care professionals who were actively practicing and providing care to patients undergoing active cancer treatment in the United States were recruited via social media (e.g., Facebook and Twitter) and email listservs through the researchers' academic institution and via national, professional and community-based organisations. A variety of oncology health care professionals (e.g., oncologists, nurses, advanced practice registered nurses, pharmacists, mental health counsellors and genetic counsellors) were invited to join the study to get broad perspectives from those working in the field of oncology during the COVID-19 pandemic. All interviews were conducted via telephone and audio recorded by the principal investigator (PI) (V. M.), who is professionally trained and experienced in qualitative methods and interviewing. Interviews lasted between 35 and 45 min on average. Recruitment and interviews continued until data saturation was met or no new information was being revealed by participants (Guest et al., 2006; Weller et al., 2018) . Interviews were scheduled according to the order in which participants contacted the PI. Once the study closed, those contacting the PI via email were notified that recruitment had been halted and data collection was complete. Participants received a $20 gift card for partaking in the study. Data were collected from May to July 2020. Interviews were transcribed verbatim. Applied thematic analysis techniques were used to analyse the data (Guest et al., 2011) . A codebook was developed using a priori (e.g., question domains Table 1 ) and emergent codes. Emergent codes were generated after research team members, trained and experi- Thirty participants completed the study, representing various oncology occupations (Table 2) . Registered nurses encompassed 70% of the sample. Employment characteristics are listed in Table 3 . Three themes emerged, which are described with supporting quotes below. 4.1 | Theme 1: Ability to adapt and operationalize disaster planning, training and restructure nursing models Many cancer centres were able to adapt and prepare for the worst of the COVID-19 pandemic using a variety of strategies. They began developing or updating current disaster planning training, simulating disaster drills both on and off health care campuses, and organising staff according to specialty and experience. In addition, nursing models were reevaluated to meet the changing need of oncology patients during the pandemic. Such nursing models were critical to consider as some outpatient oncology clinics closed or experienced low census as care shifted to telehealth visits, whereas other units had to adapt to account for surges in COVID-19 positive patients requiring hospitalization. One advanced practice registered nurse described how her organisation set up off-campus triage centres in preparation for high waves of patients, practiced COVID-19 related drills, and organisational leadership restructured nursing models to be prepared for unexpected events during the pandemic: We set aside the convention center to be our highest level of surge triage-Now that has been identified as something that can be operationalized… Some of the drills that we have actually been able to have the time to practice, they also ran a drill of [personal protective equipment] was stolen from our central hub. What do we do? New York did not have the opportunity or the benefit of being able to practice those things like we have, and that's probably what's put us in a better situation currently… the ICU was full and that they had to start moving patients and using other areas, either within the hospital or making accommodations to use the convention center. The fact that we could train nurses in a different model to be ready… We selected all of the certifications and work experience of all the advanced practice [nurses], and that was put into a master spreadsheet. Then leadership was able to kinda-I think they used like one, two, and three to prioritize Given your current experience with the COVID-19 pandemic, how will you best prepare for potential future pandemics or national emergencies? How can the oncology profession in general be better prepared in the future? 3. Given your current experience with the COVID-19 pandemic, how has your employer implemented changes to plan for potential future pandemics or national emergencies? What professional organisation, if any, have you relied upon to give you updated information on the COVID-19 pandemic and current practice guidelines to follow? • What type of education and announcements from these professional organisations has been the most helpful? • Where do you go to get the most up to date news regarding the COVID-19 pandemic? T A B L E 2 Demographics and employment characteristics of oncology health care providers (N = 30) Our study is one of the first to evaluate the perceptions of emergency preparedness among oncology professionals during the COVID-19 pandemic. Since our study, several recommendations from state and national organisations have surfaced; however, the way in which this information is disseminated and employers trained is up to individual oncology organisations (National Comprehensive Cancer Network, n. d.; American Society of Clinical Oncology, 2020). We found that overall, participants felt their organisations did an adequate job of organizing cancer care during the pandemic, but policies and procedures were reactive and not proactive. This led to several recommendations for planning for future pandemics or other national emergencies in the oncology setting, but many of these recommendations can be applied to other fields nursing or nursing specialties. First, ensuring adequate PPE was the most frequently mentioned priority. Forty percent of the participants experienced such a shortage during the pandemic ( (Ali et al., 2020) , cancer care differs in that some treatments cannot be completed remotely or be delayed without causing poor patient outcomes or even death. Participants, notably oncologists, relied upon guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology. However, these guidelines were not necessarily available at the start of the pandemic. Similar challenges during the pandemic have been reported and have resulted in international collaborations to determine best practices in oncology care during a pandemic (Segelov et al., 2020) . Lastly, our study found that over 93% of participants utilized telehealth in some form during the pandemic, which aligns with the World Health Organization's recommendations to utilize existing digital platforms during the pandemic to help control COVID-19 exposure while continuing cancer care (Salako et al., 2020) . Although it is hard to adequately compare pre and post COVID-19 telehealth use in this population as Medicare and Medicaid expanded the approved use of telehealth services during this time, there are reports of tremendous adoption of telehealth during the pandemic (Bestsennyy et al., 2020; Koonin et al., 2020) . There were concerns regarding how telehealth visits would be billed and reimbursed by their organisations, which has also been noted by Al-Shamsi et al. (2020) . Such concerns were heightened in oncology facilities that were impacted financially, reducing employee hours, or furloughing employees. Participants felt the need to plan for the use of technology in the future by training employees and understanding the billing and reimbursement. Although Medicare and Medicaid did increase telehealth service coverage and improved provider payments for telehealth services (Koonin et al., 2020) , these changes were made in late March, and employees felt they were not educated and trained. Another important factor described by participants was the lack of knowledge using technology among older patients and those with language barriers. As Battisti et al. (2020) noted, telehealth is especially important among more vulnerable patients with cancer such as the elderly or those with chronic conditions to reduce exposure. Most participants in our study were knowledgeable about their organisation's COVID-19 task force. They found that these task forces were helpful in the distribution of information related to COVID-19 to safely care for their oncology patients. Ueda et al. (2020) has also noted the critical nature of having command centres during a pandemic to centralize dissemination of information. These results are important given reports of oncology nurse distress due to numerous practice changes and information overload during the pandemic (Barello et al., 2020; Segelov et al., 2020) . Participants distrusted media sources and often felt they were experiencing information overload. Such sources of information overload during a pandemic have been referred to as an infodemic, where individuals are bombarded with information and cannot decipher what is reliable and what is not (Merchant et al., 2021; Tangcharoensathien et al., 2020) . This is especially difficult in the era of social media (Merchant et al., 2021) . Oncology professionals relied upon the COVID-19 task forces and other information from their administration. They also supplemented their knowledge by seeking information from state and federal agencies and their specialty or professional organisations. Many noted, however, that despite receiving information from these reliable sources, they ultimately went with the recommendation of their organisation to ensure they were following the outlined policies and procedures needed to comply with their employer in the event there was a contradiction. The pandemic will undoubtedly have an impact on the education of nurses. Future directions should include the training of nursing students and new nurses on emergency preparedness that can assist in the pandemic response (Veenema et al., 2020) . Strategies for schools of nursing and universities to enhance the inclusion of emergency preparedness and pandemic response may include updated curriculum and clinical experiences involving COVID-19 testing, vaccine education and rollout, and vaccine administration (Veenema et al., 2020) . Overall, oncology professionals believed that their organisations were able to adapt during the pandemic, but most policies and procedures were reactive and not proactive. Recommendations for planning for future pandemics or other national emergencies included ensuring adequate PPE, developing cancer-specific guidelines and algorithms to prioritize cancer care, and telehealth training related to billing and reimbursement. Professional organisations were reliable resources of information during the pandemic, but oncology professionals ultimately trusted their employer to distribute information needed for safe patient care, which has steep implications for nurse managers responsible for disseminating and implementing new policies and procedures that are so fluid during a global pandemic. 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Data are available upon request. Please contact Victoria Marshall, PhD, RN (vkmarshall@usf.edu). https://orcid.org/0000-0001-9010-9314