|Year : 2022 | Volume
| Issue : 1 | Page : 24-31
Contracting infection among registered nurses working in coronavirus disease units: A qualitative case series
Seema Verma, Mahalingam Venkateshan, Asha P Shetty
Department of Nursing, College of Nursing, AIIMS, Bhubaneswar, Odisha, India
|Date of Submission||13-Oct-2021|
|Date of Decision||20-Mar-2022|
|Date of Acceptance||22-Mar-2022|
|Date of Web Publication||23-Jun-2022|
Dr. Asha P Shetty
College of Nursing, AIIMS, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Background and Aim: Nurses are the backbone of any health system, providing quality care to the patients in the Coronavirus disease-2019 (COVID-19) pandemic. They are working as frontline warriors in this pandemic and giving their services in such challenging and difficult situations. Since nurses have high rates of exposure they are at risk of getting the SARS CoV-2 infection. The aim of the study is to explore the contributing factors for (COVID-19) infection among nurses working in COVID-2019 units. Background: Nurses are the backbone of any health system, providing quality care to the patients in this COVID pandemic. They are working as a frontline warrior in this COVID-19 pandemic and giving their services in such difficult situations. Nurses have direct patient contact which makes them at risk of getting an infection. Materials and Methods: A qualitative case series design was carried out using conventional thematic analysis through an inductive approach to explore the factors. Fourteen nurses who have turned COVID-19 positive within 7 days of their last working exposure to COVID units were interviewed using the maximum variation purposive sampling technique. Consolidated Criteria for Reporting Qualitative Research guidelines were used to report the study. Results: Nurses reported prolonged exposure to COVID-19 patients; challenges in the patient care environment, biological disequilibrium, and exposure to a non-COVID zone were the major factors contributing factors. Conclusion: It is necessary to make policies on regulating the adequate manpower (both number and gender adequacy) in various COVID units, training of every nurse, rotation of COVID duties among various teams, regular health checkups of nurses, and smart monitoring of COVID units.
Keywords: Contributing factors, coronavirus disease units, coronavirus disease-2019 infection, registered nurses
|How to cite this article:|
Verma S, Venkateshan M, Shetty AP. Contracting infection among registered nurses working in coronavirus disease units: A qualitative case series. Arch Med Health Sci 2022;10:24-31
|How to cite this URL:|
Verma S, Venkateshan M, Shetty AP. Contracting infection among registered nurses working in coronavirus disease units: A qualitative case series. Arch Med Health Sci [serial online] 2022 [cited 2022 Jun 25];10:24-31. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/24/347958
| Introduction|| |
Severely acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus pandemic created numerous challenges to the health system, especially for the nurses. A systematic review revealed that the overall proportion of health-care workers (HCW) infected with COVID-2019 (COVID-19) was 10.1% among all COVID-19 patients. Similarly, the mortality among HCWs (0.3%) was also comparable to patients (2.3%). A study conducted in Wuhan depicts that, more than half (52.06%) of the infected individuals with COVID-19 were nurses whereas 33.62% of infected cases were doctors which show that the rate of infection was higher among nurses. A study conducted in North India has shown the moderate-to-severe level of burnout in emotional exhaustion and depersonalization among nurses and showed a moderate to a high level of resilience. Another study conducted in New Delhi, India, shows that the infected HCWs were slightly older (34.7 years vs. 33.5 years) and had more males (58% vs. 50%). Results show that the HCWs performing endotracheal intubation had higher odds of being SARS-CoV-2 infected.
The study conducted in Karachi at the beginning of 2020 among frontline HCWs, depicted that working in a high-risk department, having diagnosed family members, inadequate hand hygiene, suboptimal hand hygiene before and after patient contact, improper personal protective equipment (PPE) use, close contact with patients for ≥12 times/day, long daily contact hours for ≥15 h, and unprotected exposure are some of the factors which contributed for their COVID-19 infection. As the world is still under the arms of COVID-19 and expecting the other variants of COVID-19 in the upcoming time, it is essential to know the factors contributing to the infection to prevent our health-care army from future crises. The vaccine has also demonstrated its role but still, the chance of getting an infection is present. Thus, we strive to manage or minimize such factors/practices which can increase the incidence of COVID-19 infection among nurses. The nurse's experiences in the COVID pandemic must be acknowledged and taken into consideration for developing a body of knowledge to improve nursing issues. Various rapid reviews have suggested the risk factors contributing to the occurrence of COVID-19 infection among health-care workers despite PPE being still in the infancy stage. This proposed research intended to answer the following question: what are the contributing factors for the COVID-19 infection among nurses working in COVID units?
| Materials and Methods|| |
A qualitative case series design was adopted to explore the contributing factors for the COVID-19 infection among registered nurses working in COVID units. The study was conducted in Odisha, an Indian state located in Eastern India from September to October 2020. A sample of 14 registered nurses was selected by maximum variation purposive sampling for their diverse working experience in COVID units (COVID operation theater [OT], intensive care unit [ICU], wards and transportation team), educational status, and gender. The inclusion criteria were nurses working in COVID units who got COVID 19 infection within 7 days of their last exposure to COVID units. The participants were recruited purposefully through the COVID-19 contact tracing team of the Institute, and a total of 92 nurses came COVID-19 positive in September and October 2020. Among 92 nurses, 70 were excluded due to the primary source of COVID-19 infection being from non-COVID areas (decided through contact tracing team policy) and those who got an infection after 7 days of COVID unit exposure. The nurses who met inclusion criteria are called for the scheduling of the interview, those who agreed were followed up for data collection. Total 22 nurses met the inclusion criteria, and 14 participants were included in the study where the data saturation has reached. The data were collected through a validated semi-structured in-depth interview guide (IDI-guide) for an IDI. Face-to-face IDIs were conducted with registered nurses in a separate room in the hospital setting. Interviews are conducted in the participant's preferred language, i.e., Hindi or English. The conversation was recorded on a digital device. The interviewer initiated the interview by self-introduction and by explaining the purpose of the study and assuring confidentiality of the participants. The consent was obtained for the digital recording and interviewer-initiated interview with an open-ended rapport-building question “how is your health now?” to gain the trust and confidence of the participant. A total of seven open-ended questions were asked with some probes in between interviews. The recordings were saved by coding each interview with respondent R1, R2, R3, R4, etc., to maintain the anonymity of participants. The approximate time for a single participant interview was from 15 to 35 min. [Table 1] shows how the credibility and reliability (rigor of the study) is maintained by the authors. To support rigor of the study COREQ (Consolidated criteria for reporting qualitative research) checklist has been added to the study. The study was approved by the Institutional Ethics Committee, All India Institute of Medical Sciences, Bhubaneswar, Odisha (Reference number-T/IM-NF/Nursing/20/119). Written consent from the participants was obtained before data collection and insured the use of the patient data for research purposes only. Digital consent for recording the interview was also taken by all the participants. The confidentiality and anonymity of the participants were ensured throughout the study.
|Table 1: Consolidated criteria for reporting qualitative research checklist|
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All the IDIs were digitally recorded, transcribed, and translated into English. The inductive approach was followed for the analysis of data. The computer software ATLAS. ti 9.0 Scientific Software Development GmbH, Berlin was used to analyze the data, condense the data codes, subthemes, and themes. The meaning units, i.e., parts of the original text that were relevant to the purpose of the study were identified from the interview transcript. The meaning units were coded, which resulted in a total of 66 codes and similar codes were groped and collapsed into 15 subthemes. These 15 subthemes were further condensed to form 5 themes in the primary analysis. After secondary analysis, 4 themes and 11 subthemes have emerged.
| Results|| |
Section A: Sociodemographic data
Section A deals with the distribution of participants according to their demographic characteristics. Collected data was analysed using descriptive statistics. As depicted in [Table 2], the age of the participants ranges from 25-33 years with a mean age of 28.21±2.914. the 71.4% of the participants were male. The 78.6% of the nurses had B. Sc Nursing as an educational status. The 92.9% of the participants were regular employee. The majority (71.4%) of nurses had total experience of 1-5 years. and only 14.3% - had less than 1-year total experience. None of the participant had experience of more than 5 years, the majority (78.6%) had 1-5 years of experience at present working institute. Less than half (42.9%) participants have done duties in COVID wards, and 21.4% study participants have done duties in COVID wards, COVID ICU and COVID OT. Both the married (50%) and unmarried (50%) participants were included in the study. All the participants (100%) were grade-II nurses. None of the nurses had high risk exposure other than hospital.
Section B: Themes and subthemes
The findings were illustrated through an inductive process of data analysis. After coding the significant statements from the transcript of participants, they are condensed to subthemes and subsequently subthemes to themes. The findings are supported by the quotes from the participants. [Table 3] shows how themes and subthemes emerged from condensing the codes.
Theme-1: Prolonged exposure in coronavirus disease zone
Subtheme-1.1: Sustained patient contact
Nurses reported getting COVID-19 infection as they have been posted longer days of COVID duty due to the staff shortage. The patients who are very sick and unstable need nurses' continuous supervision and nurses need to perform frequent aerosol-generating procedures like suctioning for these patients.
“In the COVID area, we were doing open suctioning as close suctioning was not there. We had to expose ourselves to the open suction, which means whatever the time is 6 h, full 6 h we have to stay nearby of patients only” (R1).
“We are not having sufficient staff here. So, there are repeated exposures in COVID areas every 15–30 days. We have to do our duty in any of the COVID area either COVID ward or COVID–ICU” (R5).
Subtheme-1.2: Indecorous duties
Nurses portrayed difficulties in the COVID duties as the duties were for 6 h which they found to be lengthy and uncomfortable to be in PPE. They especially mentioned the night shifts are difficult due to the physical discomfort. “Nightshift starts from 8 pm and finished at 2 am. At this time, we have transportation issues even the hospital is providing accommodation for staying but then also you have to leave our residence around 5 am. So, the sleep cycle got disturbed and due to the disturbed sleep cycle, you may have GI disturbances” (R4).
“When doing the night shift for 6 h, it would be 2:00 o' clock so we had a headache. Then immediately, we will come and in hurry will try to remove the PPE kit so that we can go home and take shower. As the nighttime is not comfortable so by doing a little hurry, we are not following a proper doffing process” (R14).
Subtheme-1.3: Inappropriate layout
Nurses expressed that the structure of COVID units is inappropriate as the nursing station is in the center whereas both PPE and non-PPE nurses were staying together. As the patients have access to come to the nursing station and can expose nurses directly. Furthermore, entry and exit of the COVID unit from the same door can be the factor for COVID-19 infection among nurses.
“In the COVID ward, the nursing station is in center, which shouldn't be it should be separate. The one who is wearing PPE should only go inside. Because the patient comes to the nursing station where everybody is sitting in the middle of the ward. So according to me, the nursing station should be separate, then it will be best” (R8).
“In the COVID ward, the thing is after doffing if we can go through another way then it will be good rather than coming through the same ward itself. A separate entry and exit way should be there in COVID wards” (R12).
Theme-2: Challenges in the patient care environment
Subtheme-2.1: Resource maintenance
Manpower inadequacy according to the number of patients and malfunctioning ventilators, monitors and elevators can also influence the infection.
“We all are humans; we will get exhausted and it is much beyond our maximum. We can't do. We can't manage in normal settings also; we can't manage four ventilator patients. In PPE for managing four ventilator patients means it is somewhat very-very difficult, you can't manage. So, that kind of thing causes severe mental and physical distress among us people” (R5).
“Maximum exposure happened during that day when one patient got intubated. During that day 1 ventilator didn't work during intubation, till then I was doing an artificial manual breathing unit (AMBU) on the patient. I was continuing AMBU for 1 h. After some time, the ventilator was brought from another ward and then attached to the patient” (R7).
Subtheme-2.2: Challenges with personal protective equipment
Physical discomfort while in full PPE like vision problems due to fogging of the goggles or face shield, sweating, and pain especially procedures like IV cannulation or taking ABG samples made nurses breach the PPE during duty hours.
“We can't see everything because we are wearing goggles and above face shield. After sometimes fog and pain will be there if wearing for a long time. So, it's difficult to do or perform a procedure, we can't even see the vein. In some situations, after some time we feel it's difficult, so we remove the face shield or goggles” (R3).
“I was getting PPE every day, but the problem is this only the size. The correct size we are not getting, so that was the only problem. We are getting the PPE but if we are not getting the appropriate size then we are feeling like the air is passing through the cap, so I think that will be the reason for infection… if the PPE is of the correct size, then it will be more preventive” (R12).
Subtheme-2.3: Suboptimal preventive strategies
Negligence like not wearing a face shield or goggles to avoid vision fogging during patient care activities and adjusting the PPE while performing aerosol-generating procedures also leads to COVID 19 infection among nurses.
“The goggles and face shield, we can't wear continuous for 6 h, means we get pain here (behind ears). We used to write nurses' reports with goggles only and it's very difficult so at that time we used to remove face shields, because of that, maybe I was thinking that might be the cause of infection” (R1).
“During an emergency, we may neglect ourselves and forget to follow the PPE or safety measures. In such situations, the kit may be open, the mask may have some space, so the virus can enter” (R3).
Theme-3: Biological disequilibrium
Subtheme-3.1 Impairment in physical well-being
Nurses with low immunity, not following COVID prophylaxis strategies, and improper dietary habits can also influence the infection.
“If the nurses are not taking good prophylaxis against COVID-19 after their COVID duties and dietary intake also if not taken properly it can be a risk factor for getting an infection. Because if you are doing a continuous COVID duty then prophylaxis is mandatory” (R6).
“According to my experience, the reason could be like already I am asthmatic, and other could be due to immunity or some eating habit. Because of skipping breakfast in the morning time, we are prone to get a COVID infection” (R11).
Subtheme-3.2: Existence of comorbidities
Nurses portrayed that other coexisting health problems can be a risk factor for getting COVID-19 infection among them. Few nurses were having other comorbidity which they found to be a risk factor such as sinusitis, rhinitis, asthma, or some other respiratory disease.
“A 7 h job we are doing in PPE. Already I am a known case of having lung infiltration diseases, so in such cases, we are not able to maintain our health properly. And … we won't be means…. Physically and mentally, we can't take adequate care of our health at these points. So, 15 days of continuous COVID duty is somewhat hectic” (R5).
“The risk depends upon the health status of nurses if they have sinusitis, rhinitis or any respiratory problem. If they already have such problems, then they are more prone to infect with COVID-19” (R6).
“I am asthmatic and allergic too, so it might be a cause for getting an infection. Because we are doing repeated COVID duties with the patient and getting exposure” (R11).
Theme-4: Exposure to noncoronavirus disease zone
Subtheme-4.1: Devoid of personal protective equipment
Nurses reported working in non COVID units like general wards, OT, ICU as a risk factor where PPE kits are not available. In such area's after some days, patients are diagnosed with COVID infection. Hence, the chances of getting an infection are more, as they have direct contact with asymptomatic patients. Casualty is a high risk area where the nurses are working without PPE and are more susceptible to get the infection.
“In an emergency, we can't anticipate which patient is COVID positive because after screening also they can be positive. After screening, they will come to the emergency where we are not wearing PPE and after a few days, we came to know that the patient is positive. So, there we are not wearing a PPE kit, we are just wearing a plastic apron or gown only. So, it's also a factor for getting an infection” (R3).
“We are working in critical ICU, many times… many times those patients who are getting admitted as COVID negative became positive. Because we are not wearing PPE inside the ICU. I remember one patient who was in CICU and she came to CICU by testing negative and around five to six nurses who have taken care of this patient became COVID positive” (R5).
Subtheme-4.2: Exposure from community
Few registered nurses expressed the possibility of COVID-19 infection from the outside environment as they are going out for their necessary work to do or to buy essential items like groceries and handling the eating stuff.
“I had exposure to COVID patients, which can be a possibility for the infection. Another possibility is grocery, from where we are buying vegetables and other eating material” (R4).
“Now like traveling is allowed, everything is open now so there can be chances” (R10).
“We are buying things for eating purposes. If we are now washing vegetables and other stuff properly and using it could be a source of infection as we don't know from how many people, it is coming through. Also eating food from outside, that could be a reason” (R11).
Subtheme-4.3: Uncertainty of possible infection
The possibility of COVID 19 infection among nurses was added because they are having exposure in COVID units as well as community areas such as their own houses, markets, and other public places.
“We will be exposed, not only in COVID ward, anywhere we can be exposed because we are going outside, and we are using lift sometime, even though you are wearing an N-95 mask, still there is a chance” (R2).
“From where we got an infection, how do we know this? There are asymptomatic colleagues also. In the ward there is no PPE, maybe in the ward, it happened. Or maybe outside when we are going to buy the vegetables there it may happen we don't know anything” (R8).
| Discussion|| |
The study has found a few factors that might be contributing to COVID-19 infection among nurses, but at the same time, study has some limitations. We used one method of data collection, i.e., the interview method. Data collection was done from those nurses who came COVID-19 positive 1 month ago from the data collection period, which can lead to recall bias. Memos and other field notes could have been made in the study.
The present study explored that exposure to an infected patient for a long period in a shift may contribute to COVID-19 infection. Our findings are supported by previous evidence where prolonged patient contact mainly through working in high-risk departments and contaminated fluids/aerosols is contributing to COVID-19 infection among HCWs. Another study found to be congruent where close patient contact more than 12 times/day and long daily contact hours of 15 h is contributing to the infection. The cause for the positivity was patient exposure at a distance <1 m and a contact time >2 h. The present study reveals that procedures such as intubation, nebulization, oxygenation, and CPR are associated with a higher risk of getting COVID-19 infection which is supported by the previous findings where procedures like intubation or contact with bodily secretion were evident. Long duty hours for >10 h/day were also significantly associated with the infectivity rate.,
The nurses experienced various challenges related to the manpower and PPE shortage, which compels them to breach the PPE and results in suboptimal preventive strategies.,Similar findings are also reported by other researchers where staff shortage and lack of medical supplies and equipment were associated to the great extent. The major problems in PPE were sweating, exhaustion due to heavy workloads, and protective gear. Some nurses due to unbearable discomfort in PPE are compelled to adjust their PPE gear or sometimes remove to work efficiently in COVID areas which result in suboptimal preventive strategies like removing PPE (goggles, face shield, etc.) and not wearing face covering while interacting to patients.
It was also evident that those who had impaired physical well-being or co-morbidities were at risk for COVID-19 infection. The study finding was found to be in congruence where nurses working in night shift felt working under pressure than uninfected HCWs. Sleep disturbance was highly evident among them. The participants expressed due to their hectic schedule; they are not able to take care of their nourishment either by skipping meals due by exhaustion. Nurses expressed that having asthma, hypertension, diabetes, and immune-compromised individuals are at risk for getting COVID-19 infection. Contrary to this other study supports, there is no significant difference between the presence of comorbidities and COVID-19 infection among health-care workers.
Nurses expressed that working in non-COVID areas without PPE is also a high-risk factor for getting COVID-19 infections such as casualty (trauma and emergency department) and ICU/wards as there is more interventional aerosol-generating exposure. They were also having the opinion regarding exposure from an outside environment like from shops, market as they are going to buy something for their daily needs. Furthermore, they can get an infection from other infected colleagues (45%) and patients (29%).
Protocols should focus on developing preventive measures by smart monitoring and assistant system in the doffing area. Both quantity and quality aspects of nursing manpower should be kept in mind by fostering adequate training/teaching programs. The manpower planning should not only hyper focus to the nurse: patient ratio but also attention should be given to maintain the male: female nurses ratio which plays an important role in management of pandemic. The policy should focus on appropriate planning and construction of COVID units, procuring suitable PPE kits for the health-care workers, regular health checkups and abstaining comorbid employees from COVID duties, and also keeping a check on hospital gadgets functioning.
| Conclusion|| |
In conclusion prolonged exposure to COVID-19 zone, challenges in patient care environment due to the improper manpower, malfunctioning of the articles, physical discomfort plays an important role in COVID infection. Other factors like biological disequilibrium of nurses also influenced the occurrence of COVID-19 infection. Their own preventive measures like drug prophylaxis, supplement intake, adequate rest and sleep can influence the COVID-19 infection. Exposure to non-COVID zone can also be another factor in terms of working in areas without PPE like casualty, ICU, and wards. As there is no standard treatment for COVID infection till now, the ultimate option is to prevent the people from unnecessary exposure. First-line healthcare workers should be provided with adequate manpower, good quality articles/PPE and a well drafted protocols for smooth functioning od the units
We express sincere thanks to our esteemed institution, the All-India Institute of Medical Sciences. Bhubaneswar, Odisha, India, for providing ethical clearance to conduct the study. We owe our gratitude to all the participants who enthusiastically and voluntarily participated in carrying out the research study. We appreciate their keen interest, patience, and co-operation extended for successful completion of the study.
Financial support and sponsorship
The authors received no financial support for the research, authorship, and/or publication of this article.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]