Psychosocial impact of the COVID-19 pandemic on Australian nurses and midwives: a cross-sectional study

Keywords: Australia;COVID-19;hospitals;nurses;midwives;mental health OBJECTIVE At the time the study was conducted (May-August 2020), most of the published peer-reviewed evidence about the impact of the COVID-19 pandemic on nurses and midwives was from countries with high numbers of COVID-19 cases and deaths, such as China,1-2 and the United Kingdom (UK).3 Australia has recorded relatively low numbers of COVID-19 cases and deaths in comparison to other countries.4 Although evidence is starting to emerge about the impact of the COVID-ig pandemic on Australian nurses' and midwives' psychological wellbeing and their work and personal lives, most studies have been conducted in a single setting,5 or have included nurses and midwives as part of a broader investigation of healthcare workers in general.6,7 Recent reviews about the prevalence of psychological distress among nurses during the COVID-19 pandemic have identified few studies that have been conducted in more than one setting and none of these were from Australia.8,9 Understanding the impacts of the COVID-19 pandemic on nurses and midwives is important in planning appropriate support services, ensuring nurses and midwives can provide high quality patient care, and optimising their psychological wellbeing.10 The aim of this study was to investigate the psychosocial effects of the COVID-19 pandemic on nurses and midwives working in Melbourne, Australia, specifically psychological distress, self-reported concerns, and perceived impact on their work and personal lives. During previous outbreaks of infectious diseases such as Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and H1N1 influenza, healthcare workers reported concerns about their own and family members' health.17"21 A recent Australian study conducted during the COVID-19 pandemic found that most of the hospital clinical staff surveyed were also concerned about their own health and infecting their families, friends and colleagues.22 Further research is required to identify other concerns nurses and midwives may have experienced during the pandemic or are specific to COVID-ig as well as the effects of the pandemic on their personal and work lives and psychological wellbeing. Services in private hospitals are paid for directly by patients or their health insurer.23 Nurses and midwives were recruited from four major metropolitan health services in Melbourne, the capital city of the State of Victoria, Australia;three are public health services which provide acute tertiary services, subacute care, specialist clinics and community health services. Sociodemographic and employment characteristics: sex, age, country of birth, professional role (e.g. nurse, midwife), living with school-aged children (yes/no), employment status (full time/part time/casual),years of clinical experience and years employed at health

Patient perceptions of care quality and discharge information following same-day cardiac catheterization laboratory procedures: A mixed-methods study.

AIMS: To examine patients' perceptions of care quality following a same-day procedure in the cardiac catheterization laboratory and understand the extent to which they were prepared for discharge. DESIGN: Single-centre, mixed-methods study. METHODS: Postdischarge, online survey of patients who underwent a same-day procedure in the cardiac catheterization laboratory (n = 150) and one-on-one interviews with 13 of these patients. RESULTS: Survey responses were positive with mean scores between 4.39-4.83 out of five and 63.3% of respondents (n = 95) extremely likely to recommend the service to others. Interview data analysis identified three themes: the care experience, information and education for safe discharge, and follow-up needs. Participants spoke highly of their interactions with clinicians and were satisfied with their care experience. Mode and content of information delivered varied, with some participants lacking guidance about postdischarge health management and clarity about follow-up plans. PATIENT OR PUBLIC CONTRIBUTION: Participants were patients.

Perspectives of family-centred care at the end of life during the COVID-19 pandemic: A qualitative descriptive study.

AIM: To explore nurses' and family members' perspectives of family care at the end of life, during restricted visitation associated with the COVID-19 pandemic. BACKGROUND: To minimise the transmission of COVID-19, stringent infection prevention and control measures resulted in restricted hospital access for non-essential workers and visitors, creating challenges for the provision of family-centred care at the end of life. DESIGN: Qualitative descriptive approach based on naturalistic inquiry. METHODS: At a large public hospital in Melbourne, Australia, individual semi-structured interviews were undertaken with 15 registered nurses who cared for patients who died during restricted visitation associated with the COVID-19 pandemic, and 21 bereaved family members. COREQ guidelines informed analysis and reporting. RESULTS: Five themes developed from the data: (i) impact of visitor restrictions, which describes uncertain, ambiguous and arbitrary rules, onerous and inconsistent requirements; (ii) nurse-family communication; (iii) family-centred care and interrupted connections; (iv) well-being and negative emotions; and (v) suggestions for a better way, such as moving away from the black and whiteness of the rules, prioritising communication, compassion and advocacy. CONCLUSIONS: Negative consequences for communication and the patient-family connection at the end of life were felt deeply. The evolving COVID-19 rules that were frequently revised and applied at short notice, and the subsequent consequences for clinical practices and care were felt deeply. RELEVANCE TO CLINICAL PRACTICE: Technology-facilitated communication, innovation and increased resources must be prioritised to overcome the challenges described in this study. A family-centred approach to care and emphasising the patient-family connection at the end of life is fundamental to minimising trauma and distress associated with future public health emergencies. PATIENT OR PUBLIC CONTRIBUTION: Bereaved family members contributed their first-hand experience. Members of the health service's patient experience team ensured the research was conducted in accordance with health service guidelines for patient and public contribution.

Informal carers' support needs, facilitators and barriers in the transitional care of older adults: A qualitative study.

INTRODUCTION: Inclusion of informal carers in transitional care is challenging because of fast throughput and service fragmentation. This study aimed to understand informal carers' needs during the care transitions of older adults from inpatient care to the community. METHODS: A qualitative exploratory design was used with mixed-methods data collection. Seventeen semi-structured telephone interviews were conducted with family carers; one focus group was conducted by videoconference with two family carers and three community-based advocacy and aged care providers; and eight semi-structured telephone interviews were undertaken with healthcare practitioners from rehabilitation services. Data were thematically analysed. FINDINGS: All carers described the main social challenge that they needed to address in transitional care as 'Needing to sustain family'. Carers reported their social needs across five solutions: 'Partnering with carers', 'Advocating for discharge', 'Accessing streamlined multidisciplinary care', 'Knowing how to care' and 'Accessing follow-up care in the community'. Focus group participants endorsed the findings from the carer interviews and added the theme 'Putting responsibility back onto carers'. All healthcare practitioners described the main social challenge that they needed to address as 'Needing to engage carers'. They reported their social solutions in three themes: 'Communicating with carers', 'Planning with carers' and 'Educating carers'. DISCUSSION: Findings highlight the importance of reconstructing the meaning of transitional care and relevant outcomes to be inclusive of carers' experiences and their focus on sustaining family. Transitional care that includes carers should commence at the time of hospital admission of the older adult. CONCLUSIONS: Future sustainable and high-quality health services for older adults will require transitional care that includes carers and older adults and efficient use of inpatient and community care resources. Healthcare professionals will require education and skills in the provision of transitional care that includes carers. To meet carers' support needs, models of transitional care inclusive of carers and older adults should be developed, implemented and evaluated. PUBLIC CONTRIBUTION: This study was conducted with the guidance of a Carer Advisory Group comprising informal carers with experience of care transitions of older adults they support and community-based organizations providing care and advocacy support to informal carers.

Nurses' Experiences After Implementation of an Organization-Wide Electronic Medical Record: Qualitative Descriptive Study.

BACKGROUND: Reports on the impact of electronic medical record (EMR) systems on clinicians are mixed. Currently, nurses' experiences of adopting a large-scale, multisite EMR system have not been investigated. Nurses are the largest health care workforce; therefore, the impact of EMR implementation must be investigated and understood to ensure that patient care quality, changes to nurses' work, and nurses themselves are not negatively impacted. OBJECTIVE: This study aims to explore Australian nurses' postimplementation experiences of an organization-wide EMR system. METHODS: This qualitative descriptive study used focus group and individual interviews and an open-ended survey question to collect data between 12 and 18 months after the implementation of an EMR across 6 hospital sites of a large health care organization in Victoria, Australia. Data were collected between November 2020 and June 2021, coinciding with the COVID-19 pandemic. Analysis comprised complementary inductive and deductive approaches. Specifically, reflexive thematic analysis was followed by framework analysis by the coding of data as barriers or facilitators to nurses' use of the EMR using the Theoretical Domains Framework. RESULTS: A total of 158 nurses participated in this study. The EMR implementation dramatically changed nurses' work and how they viewed their profession, and nurses were still adapting to the EMR implementation 18 months after implementation. Reflexive thematic analysis led to the development of 2 themes: An unintentional divide captured nurses' feelings of division related to how using the EMR affected nurses, patient care, and the broader nursing profession. This time, it's personal detailed nurses' beliefs about the EMR implementation leading to bigger changes to nurses as individuals and nursing as a profession than other changes that nurses have experienced within the health care organization. The most frequent barriers to EMR use by nurses were related to the Theoretical Domains Framework domain of environmental context and resources. Facilitators of EMR use were most often related to memory, attention, and decision processes. Most barriers and facilitators were related to motivation. CONCLUSIONS: Nurses perceived EMR implementation to have a mixed impact on the provision of quality patient care and on their colleagues. Implementing technology in a health care setting was perceived as a complex endeavor that impacted nurses' perceptions of their autonomy, ways of working, and professional roles. Potential negative consequences were related to nursing workforce retention and patient care delivery. Motivation was the main behavioral driver for nurses' adoption of EMR systems and hence a key consideration for implementing interventions or organizational changes directed at nurses.

Change in nurses' psychosocial characteristics pre- and post-electronic medical record system implementation coinciding with the SARS-CoV-2 pandemic: pre- and post-cross-sectional surveys.

BACKGROUND: The impacts of electronic medical record implementation on nurses, the largest healthcare workforce, have not been comprehensively examined. Negative impacts on nurses have implications for quality of patient care delivery and workforce retention. OBJECTIVE: To investigate changes in nurses' well-being, intention to stay, burnout, work engagement, satisfaction, motivation and experience using technology pre- and post-implementation of an organisation-wide electronic medical record in Victoria, Australia. METHODS: The natural experiment comprised an electronic medical record system implementation across six hospitals of a large tertiary healthcare organisation. Cross-sectional surveys were collected pre-electronic medical record implementation prior to the SARS-CoV-2 pandemic in 2019, and 18-months post-electronic medical record implementation during the pandemic in 2020, and findings compared. RESULTS: A total of 942 surveys were analysed (550 pre-electronic medical record (response rate 15.52%) and 392 post-electronic medical record (response rate 9.50%)). Post-electronic medical record, nurses' work satisfaction (r = 0.23, p=<0.001), intention to stay (r = 0.11, p = 0.001) and well-being (r = 0.17, p=<0.001) decreased. Nurses' perceived competence increased (r = 0.10, p = 0.002) despite decreased autonomy (r = 0.10, p = 0.003). Two of three dimensions of work engagement worsened (vigour r = 0.13, p=<0.001; dedication r = 0.13, p=<0.001) and all dimensions of burnout increased (exhaustion r = 0.08, p = 0.012, cynicism r = 0.07, p = 0.04 and reduced efficiency r = 0.32, p=<0.001). Nurses reported more burnout symptoms (95% CI 4.6-4.7%, p = 0.036), were less engaged (95% CI 49.6-49.9%, p=<0.001) and career trajectory satisfaction decreased (r = 0.15, p=<0.001). Matched data from 52 nurses showed changes in the same direction for all items except career trajectory satisfaction, hence validated findings from the larger unmatched sample. CONCLUSIONS: Implementation of an electronic medical record immediately followed by the SARS-CoV-2 pandemic was associated with negative changes in nurses' well-being, intention to stay, burnout, work engagement and satisfaction.

Factors that influence intensive care admission decisions for older people: A systematic review.

BACKGROUND: The population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited. OBJECTIVE: The objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit. METHOD: This was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised. RESULTS: Six studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians' goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age. CONCLUSIONS: Published research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.

Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.

OBJECTIVES: To assess depression, anxiety and stress among undergraduate nursing and midwifery students during the COVID-19 pandemic, and identify socio-demographic and educational characteristics associated with higher depression, anxiety and stress scores. METHODS: Cross-sectional study during August-September 2020, using an anonymous, online, self-administered survey. E-mail invitations with a survey link were sent to 2,907 students enrolled in the Bachelor of Nursing suite of courses, offered across four campuses of a single university in Victoria, Australia. Depression, anxiety and stress were assessed using the DASS-21. Data on socio-demographic and educational characteristics, self-rated physical health and exposure to COVID-19 were also collected. DASS-21 subscale scores were compared with existing data for various pre-pandemic and COVID-19 samples. Multiple regression was used to investigate factors associated with higher scores on depression, anxiety and stress subscales. RESULTS: The response rate was 22% (n=638). Mean scores on all DASS-21 subscales were significantly higher (p<0.001) than means from all comparative sample data. The proportions of students reporting moderate to severe symptoms of depression, anxiety and stress were 48.5%, 37.2% and 40.2% respectively. Being a woman, being younger, having completed more years of study and having poorer self-rated general health were all significantly associated (p<0.05) with higher scores on at least one DASS-21 subscale. CONCLUSIONS: Almost half of participants reported at least moderate symptoms of depression; more than a third reported at least moderate symptoms of anxiety or stress. Poor psychological wellbeing can impact students' successful completion of their studies and therefore, has implications for nursing and midwifery workforce recruitment and retention. During and after pandemics, universities should consider screening undergraduate students not only for anxiety and stress, but also for depression. Clear, low-cost referral pathways should be available, should screening indicate that further diagnosis or treatment is required.

Australian and Danish nurses' and midwives' wellbeing during COVID-19: A comparison study.

Background: Most investigations of nurses' and midwives' psychological wellbeing during the COVID-19 pandemic have been conducted in a single setting. Aim: To assess and compare the psychological wellbeing of nurses and midwives in Australia and Denmark during the COVID-19 pandemic. Methods: Nurses and midwives employed at four metropolitan health services in Australia and one in Denmark completed an anonymous online survey, which assessed depression, anxiety, and stress symptoms (The Depression, Anxiety and Stress Scale - 21 Items (DASS-21)), and sociodemographic and employment factors. Findings: Completed surveys were received from 3001 nurses and midwives (1611 Australian and 1390 Danish). Overall, approximately one in seven of the nurses and midwives surveyed reported moderate to extremely severe levels of depression (n = 399, 13.5%), anxiety (n = 381, 12.9%) and stress (n = 394, 13.4%). Australian nurses' and midwives' scores on all DASS-21 subscales were significantly higher (representing higher levels of depression, anxiety and stress) than the scores for the Danish nurses and midwives. Fewer years of clinical experience, living in Australia and being employed on a part-time basis were significantly associated with higher levels of psychological distress. Discussion: A considerable proportion of nurses and midwives experienced distress during the COVID-19 pandemic; however, the proportion and severity varied by country. Australian nurses and midwives experienced higher levels of distress than their Danish colleagues. Conclusion: Nurses and midwives working in countries with relatively low numbers of COVID-19 cases and deaths are also likely to experience psychological distress. Nurses and midwives would benefit from targeted country-specific support and wellbeing initiatives.

The impact of the COVID-19 pandemic on Australian hospital-based nursing and midwifery educators.

Background: The COVID-19 pandemic significantly disrupted health services and their staff, including nursing and midwifery educators. Nursing and midwifery educators were tasked with meeting nurses' and midwives' rapidly-changing educational requirements, and supporting the nursing and midwifery workforce through the pandemic. Thus, nursing and midwifery educators were pivotal to the pandemic response. Aim: To assess the impact of the COVID-19 pandemic on nursing and midwifery educators across four large, multisite Australian health services. Methods: Qualitative descriptive study. All nursing and midwifery educators from public health services in Melbourne, Victoria (n = 3) and Adelaide, South Australia (n=1) were invited to participate in a semistructured interview (July - November 2020). Interviews were audio-recorded and transcribed verbatim. Data were analysed thematically. Findings: Forty-six nursing and midwifery educators participated in interviews. Across the health services, two similar themes and six sub-themes were identified. In the first theme, "Occupational impacts of COVID-19," participants described adjusting to providing education during the pandemic, managing increased workloads, concerns about not being able to carry out their usual education activities and the importance of support at work. The second theme, "Psychological impacts of COVID-19," included two sub-themes: the negative impact on participants' own mental health and difficulties supporting the mental health of other staff members. Participants from all health services identified unexpected positive impacts; online education, virtual meetings and working at home were perceived as practices to be continued postpandemic. Conclusions: Hospital-based nursing and midwifery educators demonstrated agility in adjusting to the fast-changing requirements of providing education during the pandemic. Educators would benefit from continued occupational and psychosocial support during the COVID-19 pandemic, and inclusion in discussions to inform hospitals' preparedness for managing the education of nurses and midwives during future pandemics.