Emergency departments (EDs) provide the general public with access to medical services and are often considered an interface between the healthcare system and the community (Boyle et al, 2015). The availability and accessibility of EDs leads to a surge in demand on them during an epidemic, which challenges their capacity to deal with it (Beysard et al, 2018). During an epidemic, the function of an ED is expected to expand beyond the provision of emergency care to play a role in public health services (Lam et al, 2016).
The increase in demand on emergency services during an epidemic also increases the importance of the pivotal role played by emergency nurses in a public health response, as they have close, frequent contact with people using emergency healthcare services (Venkat et al, 2015). To ensure the smooth provision and functioning of services during an epidemic, these professionals must competently adjust to the demands of emergency services and demonstrate nurses' ability to respond to disease situations using their skills, abilities and knowledge of infection prevention and control and disease management.
Background
Emergency nurses have a considerable role over the course of an epidemic. The evidence indicates that emergency nurses face an onerous burden at work during these circumstances (Lam et al, 2018). Both qualitative and quantitative research suggest these burdens result from increased workloads during infectious disease outbreaks (Kang et al, 2018; McMullan et al, 2016).
However, the influence of the changing nature of emergency care during an epidemic on emergency nurses remains poorly understood. Indeed, studies have largely failed to address the specific roles and practices of emergency nurses in the context of a public health response to an epidemic. This gap in the evidence may limit the general understanding of emergency nurses' perceptions of their roles in epidemic management and may lead to a failure to address their needs.
Consequently, emergency nurses' involvement in epidemic management may be hindered, which could affect the service provided during a local public health response to an epidemic. Both the nature of events encountered by emergency nurses and their experiences of practice during the management of an epidemic require recognition and clarification.
This study aimed to explore how emergency nurses understand and carry out their professional roles and practices during epidemic events. The findings provide insights into the roles and practices of emergency nurses over the course of an epidemic and are used to develop potential strategies to support the participation of emergency nurses in epidemic management.
Methods
Design
This study was based on a qualitative, descriptive design. This research approach has often been used to explore phenomena related to an individual's interactions with the surrounding context (Colorafi and Evans, 2016). Through soliciting ideas and opinions, it can be used to establish a rich description and define the meaning of a phenomenon from an insider's perspective (Bradshaw et al, 2017).
As the present study aimed to explore how emergency nurses understand their roles and practice in the course of an epidemic, the qualitative descriptive research design was considered both relevant and suitable.
Selection of participants
Twenty-four participants were recruited from 11 EDs in the Hong Kong Special Administrative Region through a purposive sampling strategy (Etikan et al, 2016).
Eligible participants were full-time frontline emergency nurses who interacted directly with patients in the ED. Managerial-level emergency nurses were excluded, as they had little direct contact with patients.
Details of the participants' demographic data are shown in Table 1.
| Participant | Age | Ranking | Years of nursing experience |
|---|---|---|---|
| P1 | 25–30 | RN | 7 |
| P2 | 25–30 | RN | 7 |
| P3 | 25–30 | RN | 2 |
| P4 | 30–35 | RN | 9 |
| P5 | 25–30 | RN | 5 |
| P6 | 45–50 | NO | 20 |
| P7 | 20–25 | RN | 1 |
| P8 | 30–35 | RN | 9 |
| P9 | 20–25 | RN | 1 |
| P10 | 25–30 | RN | 6 |
| P11 | 20–25 | RN | 3 |
| P12 | 20–25 | RN | 3 |
| P13 | 30–35 | RN | 15 |
| P14 | 30–35 | APN | 12 |
| P15 | 25–30 | RN | 5 |
| P16 | 45–50 | NO | 20 |
| P17 | 35–40 | RN | 15 |
| P18 | 30–35 | RN | 10 |
| P19 | 35–40 | RN | 10 |
| P20 | 35–40 | RN | 15 |
| P21 | 35–40 | APN | 15 |
| P22 | 25–30 | RN | 6 |
| P23 | 35–40 | RN | 15 |
| P24 | 35–40 | RN | 9 |
RN = registered nurse; APN = advanced practice nurse; NO = nursing officer
The position of nursing officer was replaced by that of advanced practice nurse in Hong Kong's public hospitals in 2002; the roles and entry requirements, however, are not identical
Ethical considerations
Ethical approval for the study, which was part of a PhD project, was obtained from the human ethics committee at Hong Kong Polytechnic University.
The study conformed to the ethical principles set out in the Declaration of Helsinki (World Medical Association, 2013), including respect for autonomy, beneficence, non-maleficence and justice. Participants' rights to informed consent, privacy and anonymity were also protected and maintained.
Data collection
Semistructured, face-to-face interviews with consenting individual participants were scheduled and conducted by the first author (SKKL). To facilitate further data management, the interviews were audiorecorded with the participant's permission.
An interview guide comprising open-ended and explorative questions was used to direct the conversation toward the areas of inquiry (Box 1) (Kallio et al, 2016). The duration of each interview ranged from 45 to 90 minutes.
Data analysis
The interviews were transcribed verbatim, and the data were subjected to thematic analysis (Braun and Clarke, 2006).
The authors first scrutinised the data to familiarise themselves with the material. Then, concepts that emerged from the data were collated to produce initial codes. These codes were then compared and connected according to their nature to develop themes.
The themes were then reviewed and refined, which established the two bridging themes of the present study: the expanded practice of emergency care; and the altered roles of emergency nurses.
Findings
Expanded practice of emergency care
In terms of the tasks and issues involved in epidemic management, participants' comments highlighted that their duties in EDs included disease surveillance, infection prevention and patient logistics.
All participants stated that they were equipped with the skills needed to perform through departmental training on infection control and precautionary measures. On the whole, they reported that the practice of infection control had been integrated into their emergency care practice as a normal component of it.
However, while disease surveillance, infection prevention and patient logistics seem to resemble the normal daily duties of emergency nurses, participants highlighted the differences between epidemic management and routine practice, stating that their work in epidemic management would be greatly and frequently influenced during epidemics.
Disease surveillance
When asked about their general views on epidemic management, most of the emergency nurses described its nature in ED as ‘gatekeeping’, and were urged to remain vigilant against various communicable diseases, notably those that had newly emerged.
A participant with experience in handling an influenza pandemic vividly highlighted nurses' pivotal responsibility in epidemic management by stating they were ‘the parts of an embankment to prevent a flood of infections into the hospitals and the community’.
A nurse who worked in the ED of a hospital that had been designated an infectious disease centre highlighted emergency nurses' important role in triage:
‘To handle those newly identified infections, I think the most crucial intervention is the initial triage assessment. A quality triage assessment can block the spread of communicable diseases in hospital. In contrast, a poorly executed triage assessment can be disastrous, opening the door to spreading pathogens to the public.’
Similar comments were made by another participant, who said nurses' role in disease surveillance was irreplaceable:
‘As the first point of clinical contact, nurses are the vanguard in handling epidemics, regardless of our assigned positions. We are sensitive to the signs and symptoms of new infectious diseases, and we know the next steps in handling patients with suspected infectious status.’
Infection prevention
In addition to being vigilant to the signs and symptoms of a potential epidemic infection, the participants said their infection prevention duties were an important practice area in epidemic management. They said that infection prevention included not only implementing infection control measures in patients but also maintaining a hygienic environment in the ED.
One described their duty of infection prevention as follows:
‘To prevent the spread of disease, we have to know what precautions to take, and what infection control measures to perform. Besides applying infection control measures around patients, we have to be aware of infection control in handling dead bodies or disposing of infectious wastes.’
Another emergency nurse elaborated on the nurses' role in environmental cleansing and disinfecting as part of epidemic management:
‘We do care about the environment of the ED, like the linens, the equipment, the stretchers and the curtains. Everything that comes in contact with patients should be disinfected, and we nurses have to ensure this is appropriately handled, in a meticulous manner.’
Patient logistics
Emergency nurses' epidemic management tasks also include patient logistics. This involves allocating patients in the ED to wards according to their infection status, and streamlining the admission of suspected infectious patients to isolation wards. One said that patient logistics was a challenging task during an infectious disease outbreak:
‘For patients with signs and symptoms of epidemic infection, we have to place them in the ED in appropriate areas in order to maintain a certain distance away from “clean” patients and minimise the risk of disease transmission. If patients require hospitalisation, coordinating patient admission is one of the most demanding duties. We have to identify isolation beds for patients who are confirmed or suspected to have an infection; if there are no beds for the patients, they will stay in the ED and accumulate there.’
Changes to the role
A number of participants reported that the majority of tasks they were responsible for during an epidemic event were associated with the minimising of infection risk. Although most nurses valued the importance of proper implementation of risk reduction guidelines and infection control measures, a number questioned whether it was appropriate for them to be assigned those tasks in managing epidemic outbreaks.
Shift from life preservation to disease prevention
A common view among participants was that emergency care practice should focus on managing patients with life-threatening conditions, and implementing first aid and emergency medical treatment. To participate in managing issues and circumstances associated with epidemic was regarded as ‘extra work’, which was, from the participants' perspectives, beyond the domain of emergency nursing practice.
One nurse, who had experience in coping with different episodes of an epidemic, noted:
‘Participating in epidemic management tends to shift the focus of emergency care from rescuing lives and providing relief to disease prevention. The functions of the ED in emergency care seems to be compromised.’
This view was echoed by another participant, who described the apparent gap between expectation and reality regarding emergency nurses' focus of work:
‘I think our role as an emergency nurse becomes extended when there is a major outbreak or epidemic. We used to handle critical patients or participate in catastrophic events or, in patients who were not critical, at least we offered treatment and relief for their complaints. At the time of an epidemic, our duty is extended to infection prevention. It could be challenging to combine these two responsibilities.’
Conflicts in standard of care
According to participants' descriptions, changes to their role not only created ambiguity in their scope of practice but also led to conflicts over the standard of care. A number of participants revealed that the change in emphasis within emergency practice had posed distressing dilemmas. One of the most harrowing examples was associated with handling patients with a suspected Ebola infection, where emergency nurses were requested to minimise or even withhold interventions for these patients.
As one participant put it:
‘We are asked to minimise interventions on patients with suspected Ebola infection to reduce the risk of disease spreading in our department. We are advised not to perform CPR [cardiopulmonary resuscitation] on these patients, even if they go into cardiac arrest and the cardiac monitor shows asystole. But I think we should still save patients if they need this.’
Another participant, asked about his impression of handling epidemics in everyday ED practice, stated:
‘Epidemic management often dominates the practice of our care. For example, if a patient came to the ED because of a heart attack, the first thing we have been asked to do is not to provide care for the patient's condition, but to verify his or her infectious status in terms of those new diseases. It is as though epidemic management has overridden our genuine practice of emergency care.’
Imposition of additional workload
Emergency nurses generally considered that tasks that emphasised the minimisation of infectious risk within departments, including disease surveillance, infection prevention and patient logistics, were additional to what they saw as their regular job specialties.
An advanced practice nurse with extensive experience in handling epidemics shared his experience:
‘I think our first priority should be treating the patients, and I expected there would be others to assist and work with us on infection control, so as to allow us to stay focused on our primary task. However, it seems that the responsibility of infection control and disease surveillance is shifted to us.’
This participant further remarked how such tasks and duties adversely influenced the daily routine of emergency nurses:
‘Ideally, both the original task of life-saving and the new role in public health protection should be maintained. However, in a real emergency care situation, if you spend your time and effort on one part, you will miss the other part. Problems will not be there waiting for you to handle them.’
Discussion
The findings show that emergency nurses are frequently assigned new roles and are required to perform unfamiliar tasks during an epidemic, and these might well be beyond the scope of their previous practice and not commensurately aligned with their expectations.
Emergency nurses are required to shoulder the responsibility of public health surveillance in the course of an epidemic, including ascertaining patients' infection status and contact tracing. They might perceive these tasks as an extra duty that are outside their usual domain of practice.
Nurses recognise their duties, responsibilities and domains of practice are subject to change, from a focus on life-saving emergency care to risk-aversion infection control.
Taken together, the findings demonstrate the problem of role ambiguity, with nurses feeling doubtful and insecure over blurred and overlapping boundaries in the roles and duties required for epidemic management. Consistent with these findings, previous studies have underlined the problem of role ambiguity among nurses in acute hospital settings, remarking on the adverse influence of unclearly articulated professional identity on clinical performance and professional attitudes (Alexander and Wang, 2015).
Nurses consider role ambiguity in a clinical context to be a major stressor, and it is associated with depleted job satisfaction, higher levels of burnout and higher levels of staff turnover (Lankshear et al, 2016). To alleviate the strains and conflicts of the nursing role, measures should be considered to reduce nurses' uncertainty over how they conceive their role. Clear role definition and job descriptions could be offered to nurses, describing the their central role in different settings and reminding them of their expanded duties in times of need (Alexander and Wang, 2015).
To strengthen emergency nurses' capacity in epidemics, education and training should be provided to equip them with the relevant skills, knowledge, and attitudes. Training and education in hospitals to prepare nurses for epidemic management often puts an emphasis on updating the technical skills required to implement infection control measures, such as hand hygiene practices and the use of personal protective equipment use (Aziz, 2016). What might be overlooked is training and practice in the acquisition and augmentation of emergency nurses' abilities in terms of decision-making and problem-solving. Therefore, as well as technical skills, educational and training should place equal emphasis on developing nurses' cognitive skills, such as critical thinking, risk assessment and balancing priorities, and should provide them with the ability to apply knowledge in chaotic and complicated circumstances.
In addition, emergency nurses' interpersonal skills should be strengthened to facilitate the establishment of a cohesive work environment that supports healthcare workers to persevere during the intensely stressful situation of managing an epidemic.
Conclusion
During the management of an epidemic event, emergency nurses have to perform activities required in addition to emergency care. This practice within emergency care creates conflicts and concerns among the nurses and, consequently, induces ambiguity regarding their roles and identities.
These findings offer insights into the introduction of strategies to bolster emergency nurses' capacity to fulfil their roles during an epidemic, including training in cognitive skills and critical thinking.