Challenges faced by direct care nurse managers during the initial coronavirus disease 2019 pandemic: A reflection

Dear editor

Health authorities in China reported to the World Health Organization (WHO) on 31 December 2019 that a new novel coronavirus disease had been identified in Wuhan, Hubei Province. Singapore had its first imported case of coronavirus disease 2019 (COVID-19) on 23 January 2020. On 30 January 2020, the WHO officially declared COVID-19 outbreak a global health emergency after seeing a sudden surge of cases in China.^1,2 Within 2 months, the WHO declared COVID-19 a pandemic, as the number of COVID-19 cases continued to increase exponentially worldwide. ¹

This COVID-19 period has brought many new and unpredictable challenges in maintaining the health-care needs of the population.^3,4 This paper outlines the challenges faced by direct care nurse managers with regards to maintaining and uplifting staff morale and revising current infection control protocols and workflows for emerging diseases during the initial period of the COVID-19 outbreak. This reflection is based on the management of an isolation ward in one of Singapore’s largest tertiary hospitals.

Morale is a person’s or group’s attitude of confidence as exhibited by their identification and receptiveness of group goals, and willingness to perform assigned tasks. ⁵ Psycho-emotional stress faced by health-care staff when handling a new virus with little known about it is a prevalent issue.^3,6 The mental well-being of nurse leaders and staff is vital, as it affects the overall team morale. A study has shown that stronger group cohesion moderated stressful situations to achieve better mental well-being of the staff. ⁷ The deputy director of nursing in charge of isolation wards demonstrated this by making daily rounds with the nurse managers to identify and manage any issues surfaced during the care of COVID-19 patients. Hence, a sense of camaraderie was formed, boosting the team’s morale. ⁴

Communication is important. Senior management leaders’ choice of words used in emails and speeches greatly helped shape the way the team perceived the situation. ⁴ Leaders who practise transparency through open and regular communication are often the key to accessing the physiological and safety needs of the team. ⁶ During roll-calls, an open-door policy and two-way communication were practised – updates were given, and feedback from the ground staff regarding their opinions on the current situation and areas for improvement were gathered and acted upon. Nurse managers have to ensure that timely psycho-emotional support is being provided to the staff. ⁸ In addition to the peer-support hotline, nurses were encouraged to approach nurse managers or medical social workers at ward level if they faced problems or experienced burn-out at work. However, while taking care of their subordinates, leaders run the risk of experiencing burn-out, and so they too need means of self-support in order to heal themselves and to give them the strength to support others. ⁹

During the initial COVID-19 period, nurses’ concerns that were addressed include:

• (1) Fear of the increased risk of infection to themselves and their family because of their exposure to positive COVID-19 patients at work.

• (2) Emotional stress resulting from being labelled as ‘dirty’ or ‘clean’ and then split into the ‘confirmed’ and ‘suspected’ COVID-19 teams, respectively.

• (3) Ostracisation from the public displayed through incidents involving, but not limited to, the discrimination of nurses in their uniforms on public transport and private hire drivers refusing to ferry nurses to the hospital. Foreign health-care staff were asked by their landlords to terminate their lease prematurely.

• (4) Deployed non-intensive care unit (ICU) staff’s fear of being inadequate in providing a higher level of care for ICU patients after going through an intensive care preparedness training course.

From global trends, nurse leaders long recognised the fact that a sudden surge in cases may potentially overwhelm Singapore’s health-care system while research is being carried out to look for an appropriate vaccine or medical treatment. ⁶ As such, while setting up new wards to cope with the increase in COVID-19 cases, they had to make sure there were adequate resources and manpower so as not to compromise patient care and staff safety.^{10 –13}

COVID-19 protocols and processes were rapidly established by infectious disease doctors, nurse leaders and the infection prevention and epidemiology (IPE) department to ensure the safety of health-care workers and patients. Leaders paid attention to making sure that high standards of infection control and safe distancing measures among health-care staff, patients and visitors were being enforced in order to prevent any potential outbreak of COVID-19 in the hospitals. With exceptions made for dangerously ill patients, a no-visitor policy was enforced in isolation wards. Staff were required to wear a surgical mask even when there was no patient contact. Social distancing between staff was a must during meal breaks and at work. IPE nurses were deployed down to isolation wards as spotters to ensure strict compliance with the infection control practices. Although creating workflows and revising existing protocols were important, dissemination of information to staff also had to be done promptly and regularly in order to avoid confusion, especially during the initial period where protocols were constantly being revised.

Despite the initial lack of knowledge about COVID-19, health-care workers globally have demonstrated resilience and teamwork by taking on roles beyond their usual job scope, adapting quickly to the changing needs and meeting increasing demands. This was evident from general ward nurses being deployed to newly created isolation areas to support isolation ward nurses. Nurse managers worked closely with the logistic department to ensure supplies were readily available. As staff busied themselves with caring for patients, nurse managers had to pay more attention to their welfare – food and drinks were provided; inter-professional care sessions with social workers were arranged for nurses to have an opportunity to share concerns affecting their psycho-emotional health.

Although this crisis may have stretched health-care resources and capacity, it has also shown that health-care leaders can orientate, adapt and act rapidly according to the situation, leading to improved outcomes.