Nurse preparedness in emergency department during the Covid-19 outbreak; n urse’s perspective

ABSTRACT


Methods
Qualitative research with a semi-structured interview technique is used in this study. The study aims to explore the readiness of nurses during the Covid-19 pandemic. Researchers involved in this study have experience in qualitative research and understand research design well. Participants who participated in this study were selected based on inclusion criteria. The Padang City Referral Hospital is a type C hospital with an emergency department operating 24 hours per seven days. These nurses had a history of serving in the ED during the Covid-19 pandemic for at least six months. Face-to-face interviews were conducted using the purposive sampling technique. 12, the population of nurses served in the Covid-19 Referral Hospital ED, and five nurses participated because they had met the saturation criteria in the data. According to the research instrument, data saturation was obtained when no new participant themes emerged. None of the participants stated that they had left the data collection process.
The interview guide used in this study was an interview with a semi-structured technique; the Collaizi technique is used in the data analysis process to determine the research's themes. The interview was conducted comfortably and in the nurse's discussion room. Only interviewers and interviewed nurses were present during the interview process. The interview process was carried out in July-August 2021. The Collaizi technique can assess the readiness of nurses and the readiness of the Emergency Room during the Covid-19 pandemic. Seven steps in the Collaizi Technique were carried out to process the results of the interviews. With the Collaizi technique, the interview results are distinguished according to clear, logical, and sequential steps to increase the validity and reliability of the data obtained. The four researchers analyzed each verbatim result to avoid personal judgments and subjectivity and ensure the results were reliable and valid.

Results and Discussion
The characteristics of the participants in this study can be seen in  Table 1 shows that more than half of the participants (60%) are women, and 60% are between the ages of 31-45. More than half of the participants had more than ten years of experience working in the emergency room, and most (80%) had worked as a Covid-19 emergency room nurse for 1-2 years. More than half of the participants (60%) have an education level as a professional nurse (Ners), and all of the respondents have a career path as a clinical nurse 2.

Research Theme
There are three themes generated in this study: Installing personal protective equipment (PPE) that is extra careful and following standard operating procedures for Covid-19 has several impacts on nurses while working. These uncomfortable impact conditions, heat, shortness of breath, and lack of communication with patients on duty. Vol. 14, No.1, January 2023, pp. 25-32 Please cite this article as: Khairina Nurses' anxiety was reduced with in-house training and direction from the Ministry of Health and coordination between hospitals in West Sumatra regarding the management of Covid-19 and how to use PPE correctly. Based on Chua, Cosmas, & Arsat (2021) the dimension that 22.7% of nurses experienced anxiety by the dimensions of epidemiology and surveillance as the main predictors.

N1
: "There was a lack of knowledge (Covid-19 management); the protection was stringent. There were no gaps, and even the air must be plastered all over the face (gaps between PPE). That is what makes it difficult for us. Still, after a team from Jakarta came in to give direction, we enjoyed it." N2: "…communicating with patients was rare, and shortness of breath when wearing it (PPE). We were afraid. If it's currently at the stage of undergoing it, so it was normal." N3: "Almost no gaps at all. Wearing two ply of gloves, wear boots too. It was just because you're afraid, right?" N5: "To reduce my anxiety, I ensure personal safety through complete PPE and continue to seek information on how the service for COVID patients should be."

4) Nursing Professional Values
Nursing professional values are one of the reasons that nurses put forward to provide nursing care to patients. Professional values that prepare the nurse to face health challenges during the Covid-19 pandemic. Emergency preparedness is one of the essential things in the management of nursing care in the Emergency Room when facing the Covid-19 pandemic. This relates to the emergency department's knowledge and capacity to actively anticipate, respond and act in the recovery phase after a health crisis (Hou, Yongchou. Zhou, Qian. Li, Dongzhi. Fan, Jingjing. Wang, 2020). Health crises are currently increasing frequently and are caused by unforeseen disaster conditions. The International Nurses Council in 2017 stated that nurses were asked to improve preparedness and develop mastery of the knowledge and skills needed to respond in an emergency (Nursing, 2017). This follows the theme of Nurse Preparation in Facing the Covid-19 pandemic, illustrated in the sub-theme of Efforts to seek new knowledge about Covid-19. Four out of five participants stated the need for adequate knowledge and knowledge to deal with the Covid-19 pandemic. Optimal expertise and knowledge regarding non-natural disaster conditions made nurses psychologically prepared. The nurses have emergency response strategies (Hou, Yongchou. Zhou, Qian. Li, Dongzhi. Fan, Jingjing. Wang, 2020) . Condition in preparedness also conveyed by Mubarak, et al. (2021)  provide a practical approach to responding to a pandemic and managing clinical situations (Mubarak et al., 2021).
The finding of this study is Preparedness from Hospital and Emergency departments (Theme 3 and Sub-theme 4). Three out of five participants stated sharing knowledge, disseminating knowledge, and updating information related to nursing care and management of Covid-19. This is also illustrated by research from Asmaningrum, et al (2022) that internal training and internal seminars by hospitals can prepare nurse competencies for developing the spread and management of Covid-19 (Asmaningrum, Ferguson, Zainur, & Kurniawati, 2022). Materials regarding training in managing Covid-19 can include infection prevention, PPE donning and doffing, and case management (Iddrisu et al., 2021).
Health workers who manage Covid-19 have an essential role in controlling the spread of Covid-19 in the community (Hou, Yongchou. Zhou, Qian. Li, Dongzhi. Fan, Jingjing. Wang, 2020). As health workers involved in ED readiness, nurses should also be supported by other participating health workers such as doctors, nurses, nutritionists, pharmacists, laboratories, and other health workers. (Hou, Yongchou. Zhou, Qian. Li, Dongzhi. Fan, Jingjing. Wang, 2020). Collaboration between health workers and colleagues can improve performance and health services to the community. In this study, this is following the third theme was preparedness in Hospital and Emergency Departments. Two out of five participants stated that synergistic collaboration between health workers is needed to provide comprehensive nursing care. These results align with Ardiana, Purwandari, Rochmawati, & Wahyuni (2020) stated in the nurse's working relationship. There is a dimension of the work-world of work relationship, which is the highest dimension in supporting nurses' quality of work, which is as much as 60.4% (Ardiana et al., 2020).
Physical and psychological issues can be overcome through interventions that have been made according to patient needs (Nursing, 2009). In addition, the readiness of each health worker, including knowledge, skills, and psychological readiness to face the Covid-19 pandemic itself, also needs to be considered by Hospital Management. Responsive hospital management and disaster teams in disaster mitigation are required (Asmaningrum et al., 2022). The efforts of the hospital management team are establishing a disaster mitigation system, and the Infection Prevention Control team and the IPC (Infection Prevention Control) team are responsible for making standard operating procedures (SOP) for patient handling and infection control. WHO (2020) has announced the crisis standard for the Covid-19 pandemic for the health care provider and also care-role responsibilities for health workers (WHO, 2020) (WHO, n.d.). The American Nurses Association 2020 also made a standard operating procedure to provide nurse care plans based on the patient's ethical standard (Association, 2020). Sholicha & Ratna (2021) states that nurses' readiness to mitigate against the COVID-19 pandemic comes from a psychological aspect, as much as 37.5 % (Sholicha & Ratna, 2021). Health workers are at the forefront of health management during the pandemic (Mubarak et al., 2021). The readiness of each health worker, for example, nurses, needs to be optimally prepared, including training on natural and non-natural disasters. Training programs and clinical practice can form mental readiness and experienced health workers to deal with non-natural disasters. The nurses can be prepared and able to provide optimal nursing care. In addition, nurses on duty during the Covid-19 pandemic are expected to be nurses who already have experience. Research from Iddrisu et al., 2021 suggests that nurses with long tenure in clinical situations dare to make clinical decisions, undertake challenging tasks, and accept responsibility for treating  cases. This aligns with the study's results that all participants on duty during the Covid-19 pandemic were nurses with clinical level 2 (Advanced Beginner). Clinical nurse level 2 is a diploma nurse with a minimum of more than four years of service and a level II clinical period of 6-9 years, or a nurse with more than three years of work experience and a level II clinical period of 4-7 years (Indonesia, 2017).
The readiness of facilities in the form of personal protective equipment and the readiness of the room can be a barrier and a good defense for nurses in providing comprehensive nursing care and holistic, bio-psycho-spiritual nursing care. Health workers, especially nurses, are assets to the state and society so in their work, they need to be given a sense of security and ensure their safety while working (Lockett et al., 2021). Few health workers or nurses have become victims of the Covid-19 pandemic. Therefore, the availability of PPE, adequate and safe room facilities, immunity and nutrition support are other factors considered by hospital management (Gordon et al., 2021) .
This study found that the theme Hospitals and Emergency Departments Preparedness showed the importance of the flow of patient care by ED essential. Nurses can be more prepared when faced with conditions at high risk of transmission. Mubarak et al., 2021 in the study also stated that nurses need Covid-19 triage and screening guidelines while on duty, as has been provided by the World Health Organization regarding readiness, critical preparedness, and Covid-19 response actions (Mubarak et al., 2021). In line with Mubarak's study, hospital preparedness and nurses are ready to triage to screen patients (Mubarak et al., 2021). Based on Khairina, Malini, & Huriani, knowledge was the most influencing factor in emergency nurses' triage (Khairina et al., 2018). Triage knowledge can divide into two dimensions triage category and screening clinical condition (Khairina et al., 2020). Nurses can develop systems related to disease development, prevalence assessment, alternative plans, and interventions to reduce the impact after a disaster in mitigation (Khairina, 2021).

Conclusion
The readiness of nurses to carry out the task of caring for Covid-19 cases needs to be considered. Nurses can respond optimally in critical situations such as the Covid-19 pandemic. Nurses' readiness includes obtaining valid information, increasing immunity, using complete PPE, and using professional nursing values to treat Covid-19 patients. In addition, there is also a need for coordination with the family, the hospital's readiness, and the emergency department itself. Hospital management, adequate resource readiness such as experienced and trained health workers, and disaster mitigation teams can respond to non-natural disasters. The hospital management needs to make internal training and seminars simultaneity, the need for a patient admission flow, and guidelines for accepting and managing patients with Covid-19. In addition to standard operating procedures for hospital management, nurse leaders should have policies to guide nurses. Nurses in the ED can provide holistic care according to ethics, well-documented disaster care, and optimal workforce planning (staffing) (American Nurses Association, 2021).

Ethics approval and consent to participate
This research has conducted an ethical test. It passed the ethical test at the Health Research Ethics Committee, Faculty of Nursing, Universitas Andalas, with the letter 016.laiketik/ KEPKFKEPUNAND.