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This study aims to explore nursing emergency management system under public health emergencies.
A descriptive qualitative study.
Semi‐structured interviews were conducted during March–November 2020 with 11 nursing emergency management administrators from 11 COVID‐19 designated hospitals and infectious disease hospitals under four administrative divisions in China, who were recruited through convenience and purposive sampling. Interviews were audio‐recorded and transcribed. Data were analysed with Braun and Clarke's inductive thematic analysis. The study adhered to the Consolidated Criteria for Reporting Qualitative Research.
Three main themes emerged from data analysis: (1) Five core elements of nursing emergency management system: Structure, Staff, System, Setting, and Supply (5S); (2) Four phases of nursing emergency management system: Reduction, Readiness, Response and Recovery (4R); and (3) operational process of nursing emergency management system (5S*4R). The findings generated a conceptual model of a nursing emergency management system.
This study provides a theoretical basis for nursing emergency management system for public health emergencies in the future. Nurse administrators could refer to this model to either review or develop their system and develop viable interventions to prepare for future public health emergencies.
Keywords: COVID‐19, nursing emergency management, public health emergency, qualitative studyIn the past few years, public health emergencies (PHEs) have occurred frequently, and become complex and unpredictable. Coronavirus disease 2019 (COVID‐19) has spread quickly worldwide since December 2019. World Health Organization (WHO) declared COVID‐19 a pandemic on 11 March 2020 (WHO, 2020). Currently, according to Johns Hopkins University, there are over 6,378,000 confirmed cases of COVID‐19 worldwide (Johns Hopkins University, 2022). As the important part of the frontline in the fight against the pandemic, healthcare workers were at great risk of infection, with an infection prevalence rate of approximately 11% based on reverse transcription polymerase chain reaction (RT‐PCR) tests (Gómez‐Ochoa et al., 2021) and an average mortality rate of 0.05 per 100,000 population for healthcare workers infected with COVID‐19 according to a survey conducted in37 countries (Erdem & Lucey, 2021). Internationally, the healthcare system, especially emergency management system, faced major challenges from the sharp increase in global morbidity and mortality rate of the COVID‐19 epidemic (Chen, Yang, et al., 2020; Wang et al., 2020).
Nurses have an important role and responsibility during the COVID‐19 pandemic. There is a global shortage of nurses, with a shortfall of about 5.9 million just before the pandemic (Buchan & Catton, 2020). During the pandemic, nurses were found to have the highest infection rates among healthcare workers (Smallwood et al., 2022). Against the backdrop of resource and manpower shortages, nurses around the world continue to perform their professional duties under difficult conditions despite the high risk of infection. They give front‐line care at the peak of the outbreak, providing personalized, high‐quality services; they need to follow the latest treatment guidelines; they should manage healthcare resources, including personnel, medicines, and materials; they are responsible for public health education, and they are effective educators who can dispel public misconceptions and help people get real information (Fawaz et al., 2020; Liu, Luo, et al., 2020; Liu, Wang, et al., 2020; Liu, Yang, et al., 2020).
In China, according to statistics, a total of 28,600 nurses were recruited from across China to support patients in Hubei during the breakout of COVID‐19 epidemic, accounting for 68% of all frontline medical workforce (Government of Hubei Province of China, 2020). As the direct leader of frontline nurses and care teams, nursing administrators were facing challenges from all aspects: a prominent shortage of infection control materials (PPEs; Asemahagn, 2020; Saqlain et al., 2020; Yin & Zeng, 2020), insufficient training and procedures of infection control (Mersha et al., 2021), persistent high workload (Danesh et al., 2021), exacerbation of burnout and exhaustion (Chew et al., 2020), insufficient support (Joo & Liu, 2021; Liu, Luo, et al., 2020; Liu, Wang, et al., 2020; Liu, Yang, et al., 2020) and psychosomatic disturbances among nurses (Huang & Zhao, 2020; Liu, Luo, et al., 2020; Liu, Wang, et al., 2020; Liu, Yang, et al., 2020; Mo et al., 2020).
The surge of patients during COVID‐19 epidemic meant that nursing administrators had to make changes to respond immediately to this unprecedented crisis, which included not only human resources but also such as supplies, equipment resources, and process methods. However, existing management systems to detect and respond to health emergencies were inadequate (GPMB, 2020). WHO advocated the need for strong and flexible emergency response systems to strengthen the current COVID‐19 response and prepare for future emergencies (WHO, 2020). Given the critical role of nurses in the fight against this epidemic, it is imperative to summarize the experience of nursing emergency management during the full cycle of the epidemic to establish a practice‐based, standardized, and scientific nursing emergency management system (NEMS) to ensure effective and timely crisis management in the event of future epidemics and to maintain the quality and safety of normal medical work.
Emergency management is defined as the administrative function responsible for establishing frameworks for hazard vulnerability reduction and crisis response in PHE management (FEMA, 2007), referring to decision‐making, planning, organizing, and commanding carried out by public administration in response to emergencies (Xu et al., 2010). In recent decades, many official standards, guidelines, and recommendations for PHE management systems have been reported. Public Health Emergency Preparedness system defined key elements of Preparedness for EU member states (ECDC, 2017; Nelson et al., 2007). Comprehensive Preparedness Guide provided Federal Emergency Management Agency guidance on the fundamentals of planning and developing emergency operations plans (FEMA, 2010). Hospital Emergency Response Checklist provided a list of priority actions to support hospital managers and emergency planners for all‐hazards situations (WHO, 2011). Surge Capacity clarified four key elements to develop optimized sustainable surge capacity (Barbisch & Koenig, 2006). However, existing management systems to detect and respond to health emergencies were inadequate (GPMB, 2020). WHO advocated the need for strong and flexible emergency response systems to strengthen the current COVID‐19 response and prepare for future emergencies (WHO, 2020b).
During the COVID‐19 pandemic, many healthcare institutions have established emergency management systems, including at the hospital level, nursing home level, department level, and department level, mainly in the following aspects. In terms of organizational structure, emergency management teams and infection control teams were set up (Huang et al., 2020; Wu et al., 2020). In terms of nursing human resource management, the Nursing Department fully exercised its functions and powers to establish three‐level sustainable security echelons and dynamically deployed human resources (Liu, Luo, et al., 2020; Liu, Wang, et al., 2020; Liu, Yang, et al., 2020). In terms of material resource management, priority should be given to the provision of personal protective equipment and medical equipment for key departments, and standardized personal protection for personnel in high‐risk areas (Cao et al., 2020; Liu, Luo, et al., 2020; Liu, Wang, et al., 2020; Liu, Yang, et al., 2020). In terms of site resources, designated testing or treatment units were provided for confirmed COVID‐19 patients and suspected COVID‐19 patients were shunted from ordinary patients (Cao et al., 2020; Huang et al., 2020; Wu et al., 2020). In terms of system and process, various working procedures, protection standards, and emergency plans have been formulated (Huang et al., 2020). In terms of support and security, rest places were provided for all nurses who have direct contact with COVID‐19 patients, and Wechat groups for psychological counselling were established.
Information technology (IT) played an important role in emergency management during the pandemic, especially during the response phase. A variety of IT‐based systems [such as surveillance systems, artificial intelligence (AI), computational methods, remote sensing sensors, Telemedicine, and geographic information system] were applied in many ways, such as improving diagnostic accuracy, early detection, ensuring healthcare worker safety, reducing workload, saving time and cost, and drug discovery (Asadzadeh et al., 2020). From a nursing perspective, for example, NoviGuide was being used as guideline‐based software to support nursing decision‐making for COVID‐19 diagnosis (Asadzadeh et al., 2020). Another recent study, based on AI technology, built the nursing monitoring system of intelligent nursing information system, which is applied to security control, medical order information, medical condition information, information query, save working time, complete the rapid delivery and accurate execution of medical orders, make the medical network communication faster and more convenient, maximize the overall efficiency (Li & Chen, 2021).
Although nurses were often on the front lines as critical humanitarian workers during PHEs, a sound NMES was needed to guide emergency management work. However, existing emergency management systems have limitations in application in the nursing field: such as applied to administrative departments rather than professional and technical managers (ECDC, 2017; FEMA, 2010; Nelson et al., 2007); limited to a certain phase of the crisis life cycle (ECDC, 2017; FEMA, 2010; Forum, 2019; Nelson et al., 2007; WHO, 2011); or only defined the key elements of emergency management (Barbisch & Koenig, 2006). Besides, little attempts had been made in terms of NEMS for PHEs. COVID‐19 epidemic brought both challenges and opportunities for NEMS, which directly affected infectious rate of healthcare workers and quality of care (Baskin & Bartlett, 2021; Kluger et al., 2020). A sound NMES can make a significant positive contribution to the fight against COVID‐19 (Wu et al., 2020).
Since there has been no study on NEMS based on PHEs practice, this study aims to explore and describe NEMS under PHEs by identifying the behaviours, attitudes, strategies, and perceptions of nursing administrators in their working experience of emergency management during the COVID‐19 outbreak.
The study was conducted in China, using a qualitative descriptive approach, and follows a standard Consolidated Criteria for Reporting Qualitative Research guideline (Tong et al., 2007).
Purposive sampling was conducted in this study. Participants are from different types of hospitals, including general hospitals and hospitals specializing in infectious diseases. participants are the director of nursing, the deputy director of nursing, or the deputy director of the hospital, directly involved in whole‐hospital nursing emergency management in designated hospitals for COVID‐19 patients in China during the early outbreak of COVID‐19 in 2020. Due to the limited transportation and high potential of infection, participants selected in the early stage were mostly from the province where the researchers were, so face‐to‐face interviews could be conducted to ensure the quality of this research. To consider the geographical, economic, environmental, and resource difference, participants were selected from four administrative regions to get full coverage of China. Sample size was determined by data saturation. The study ultimately included 11 nursing emergency management administrators from COVID‐19 designated hospitals and infectious disease hospitals in three geographic regions of China (East, North, Central and Southwest).
Before the interview, researchers were trained by experts in qualitative research. The individual interviews were conducted between March and November 2020, using telephone or face‐to‐face interviews. Interviews lasted approximately 40 min (30–59 min) and were audio‐recorded and transcribed verbatim with participant's permission. Due to the impact of the COVID‐19 pandemic, the researchers strictly followed the relevant regulations of infection prevention and control in China (Bureau for Disease Control and Prevention of China, 2020; General Office of the National Health Commission of China, 2020) during the face‐to‐face interview, and the interview site was selected in the office area (safe zone) of the hospital.
Semi‐structured interviews were guided by key questions as follows: (1) Can you please tell me what the key components of nursing emergency management in your hospital were during the COVID‐19 epidemic? (2) What difficulties and challenges did the nursing department encounter in emergency management and how did your team cope with them? (3) What do you think is the most successful aspect of your nursing emergency management? (4) To better respond to future PHEs, what other aspects of nursing emergency management do you think should be supplemented and improved?
All interviews were transcribed verbatim into Word documents as soon as possible after each case by independent transcribers. The transcribed documents were labelled with participant number and interview time, and de‐privatized. NVivo 12.0 software was used to manage the data. Data were analysed using the six phrases of an inductive thematic analysis approach, according to Braun and Clarke (Braun & Clarke, 2006): familiarization with data; generation of initial codes; searching for themes; reviewing themes; defining and naming themes; and production of the report.
Before the data analysis, two researchers were trained in data analysis, including pre‐analysis preparation, suspension principles, analysis procedures, and the use of NVIVO software. The code was read and analysed separately by two researchers. As for the differences, reach a consensus after interactive discussion. Since this study was conducted in China, interviews, transcriptions, and coding were all conducted in Chinese. Data analysis was translated into English and back‐translated by two researchers to ensure the quality and accuracy of the data.
This study strictly follows the ethical principles of human medical research in the Declaration of Helsinki. Participants were informed of the aims, objectives, and procedures of the study, and informed consent was obtained from each participant before the interview. Measures were taken throughout the study to ensure the privacy of participants and ensure confidentiality and anonymity, for example, the recordings required during the interview were made with the permission of the participants; all the names of people, places, and other identifying information associated with the participants were anonymized; and numbers were used during the study to protect participants' personal information. The study was reviewed and approved by the Biomedical Ethics Committee of Sichuan University (Approval Number: 2020 Review (198)).
The rigour of the qualitative research process means that the researcher explains the research process in detail, transparently, and clearly. It includes how to obtain research ideas, how to gain the trust of participants and get along with them harmoniously, how to collect and record data, how to code and analyse data, and how to obtain topics (Denzin & Lincoln, 1994). Descriptive qualitative research was adopted in this study, and measures were taken to ensure research process rigorous. For example, before the interview, the researchers used chat to relax the participants and establish a trusting relationship, so that the participants could fully trust the researchers and fully express their real feelings. After analysing the interview data, researchers discussed whether the coding was accurate, whether the classification was appropriate, and whether the topics accurately represented the participants' perspectives. During the data analysis, the researchers kept a reflection diary to record controversial thoughts and feelings in time to improve their understanding of the participants' inner world.
In total, 11 nursing administrators participated in this study. The characteristics of the participants are shown in Table 1 .
Sample characteristics (N = 11)
| Variable | M | SD | Number of participants | Percentage |
|---|---|---|---|---|
| Geographic region | ||||
| Southwest China | 6 | 54.5 | ||
| Central China | 3 | 27.3 | ||
| East China | 2 | 18.2 | ||
| Hospital Grade | ||||
| Grade IIA | 1 | 9.1 | ||
| Grade IIIB | 2 | 18.2 | ||
| Grade IIIA | 8 | 72.7 | ||
| Gender | ||||
| Female | 11 | 100.0 | ||
| Male | 0 | 0.0 | ||
| Age (years old) | 49.1 | 4.1 | ||
| 41–50 | 7 | 63.6 | ||
| 51–60 | 4 | 36.4 | ||
| Education | ||||
| Undergraduate | 5 | 45.5 | ||
| Postgraduate | 6 | 54.5 | ||
| Professional title | ||||
| Associate Senior professional title | 5 | 45.5 | ||
| Senior professional title | 6 | 54.5 | ||
| Nursing experience | 29.7 | 4.8 | ||
| 21–30 years | 6 | 54.5 | ||
| 31–40 years | 5 | 45.5 | ||
| Employment position | ||||
| Vice director of nursing | 3 | 27.3 | ||
| Director of nursing | 7 | 63.6 | ||
| Vice president of hospital | 1 | 9.1 | ||
Three major themes emerged from data analysis: (1) core elements of nursing emergency management, (2) phases of nursing emergency management, and (3) operational process of nursing emergency management.
Core elements of nursing emergency management were identified as the key component in NEMS, composed of five core elements (5 S): Structure, Staff, System, Setting, and Supply, which can be summarized as 5 S.
Structure means organizational structure. Emergency management needs integrated systematic planning and collaboration to give multi‐dimensional support and guarantees for front‐line nurses. In this study, structure mainly refers to Organizational structure, Quality, and safety, Coordination and cooperation, Propaganda and education, and Support and Security.
Most of the Participants focused on adjustment and distribution of existing nursing organizational structure when PHEs occurred:
Director of the nursing department ‐ Chief head nurse ‐ Head nurse, a three‐tier Organization Structure…Each role shared in this structure is somewhat different: some for the material supplies preparation, and some for the staff training…Such a division of work has already been done. (Participant 4)
Participants agreed on the importance of Quality and safety in emergencies to ensure the safety of personnel and patients:
We have set up a special quality and safety team, which is led by our quality director and specially assisted by more than two department head nurses to improve the norms in our special areas of quality and safety (Participant 8).
Coordination and cooperation were critical according to Participants, not only between all levels of the nursing department, but also between multiple departments in the hospital, between inside and outside the hospital, and between inter‐provincial and urban areas:
We set up joint meetings every day in the beginning to discuss what problems you [front‐line nurses] met. We have to cooperate and collaborate, and discuss the difficulties we had. (Participant 9)
Propaganda and education, Support, and Security were valued by most of the participants:
The propaganda and education focused more on our nurses and our patients. We published some experiences, practices, and norms, moving stories and positive propaganda reports of our nurses on some official WeChat public platforms. (Participant 8)
Most of the support was from nursing department, such as heating equipment. Regardless of food, clothing, shelter and transportation, whenever they [front‐line staff] met difficulties, we would take action to solve. (Participant 6)
“Psychiatrists were equipped in every ward. They didn't just offer psychological counselling, services and psychotherapy for patients, but also staff’. (Participant 10)
Staff is trained personnel (Adams, 2009; Phattharapornjaroen et al., 2022). During PHEs, Staff should be able to meet the needs of hospital operations under emergency conditions. As the results of this study, staff mainly means Human resource reserve, Human resource deployment, Manpower allocation, Emergency training, and Special positions.
Most of Participants focused on Human resource reserve and deployment:
We had emergency reserve teams. After the 2003 SARS epidemic, team members began to rotate in turn. Later we realized that doctors and nurses were not comprehensive, so staff from the laboratory department, ultrasound department, pharmacy and other relative departments join the team.
At first, we only had the first team. But later on, as we went through the (emergency response) process, it became clear that the emergency response team was not enough. After several infectious diseases (epidemics) occurred in our hospital in 2009, we started to set up emergency reserve personnel as the second‐tier emergency team and managed them according to the emergency team. (Participant 1)
There is a principle of human resource deployment: it can't be concentrated in a few departments, and it should be scattered to each department because we need to take the normal medical work into account. (Participant 7)
Once an emergency onset, nurse emergency administrators need to make Manpower allocation to respond to emergencies in non‐routine situations:
We made a reasonable combination of professional nurses with corresponding specialties and nurses with severe experience. Nurse's title and seniority should also be considered. (Participant 11)
Shortage of nursing manpower and nurse specialists are the biggest challenge. Nurse specialists (needs,) include many, psychological specialists, CRRT, ICU, etc. (Participant 1)
More than half of Participants focused on Emergency training for specific scenarios and knowledge:
Nursing department has set up a training department. Teachers in training department examined nurses’ knowledge of protection, as well as an emergency response to special situations. (Participant 9)
Several Participants emphasized Special positions during PHE:
We created a special position named transmission. Nurses in this position took responsibility for delivery of equipment and material supplies and didn't enter isolation wards… They can use a walkie‐talkie to inform the nurses in the isolation ward to pick up [supply]. (Participant 3)
System includes integrated management policies, guidelines and instructions that govern the quality and quantity of staff, supply and setting (Adams, 2009; Phattharapornjaroen et al., 2022). In this study, system means Emergency plan, Rules and Norms, and Process optimization.
Participants all agreed to the significance of Emergency plans:
Originally, our nursing department had emergency plans for PHEs such as earthquakes, epidemics, etc. … Once PHE occurs, emergency plan would be initiated. (Participant 9)
Most of Participants emphasized that Rules and Norms were very important for NEMS and ensuring quality and safety during emergencies. It should cover all aspects and be detailed to the implementation level for everyone to master:
With the growing quantity of patients, this thing [rules and norms] became far more important: the disinfection and isolation system, the terminal [handling process], the specimen delivery [process], [how to accomplish] patient CT, all of which should be completed before COVID‐19 's ward started. (Participant 1)
Under the leadership of a unified command, processes, systems and norms have been improved during the epidemic, so that anyone can have rules and norms to follow in any situation. (Participant 7)
Most of Participants agreed that nursing process and norms need to be optimized and improved according to the emergency continuously:
We have been adjusting, only for the ward management system we have adjusted four times, according to different circumstances and requirements at that time… under the requirements and the problems we found in the examination, we have revised the system to be more applicable and patients can understand. (Participant 4)
Setting is a structure or physical space in which to treat patients (Adams, 2009; Phattharapornjaroen et al., 2022). During the pandemic, temporary or existing infrastructure needs to be constructed or rebuilt to achieve its safety and practicability. As the result of this study, setting mainly refers to Region division and Ward transformation.
We modified the buffer room…We planned the route according to the standard of infectious disease wards. In this building [ward], even if a certain amount of space [area] may be wasted, it's necessary to ensure that staff can follow this route and wouldn't cause air convection and pollution. (Participant 1)
Pre‐examination and triage management were divided into three levels. The pre‐examination and triage region of the outpatient department was moved to the entrance of the hospital, and several independent passageways have been established for patients, healthcare workers and caregivers. (Participant 6)
Supply refers to equipment and material supplies (Adams, 2009; Phattharapornjaroen et al., 2022). In this study, it mainly means Supply management, Usage specifications and Special materials of all equipment and material in emergencies.
Most Participants agreed that Supply management should be specially assigned person in charge and strict management:
It is necessary that one head nurse needs to take the overall lead to take charge of the material support team. The material support team should be responsible for connection with support staff [other departments sometimes], equipment and material supplement for the ward, etc. (Participant 1)
Another point that was emphasized by all Participants is Usage specifications, the more authority, the better:
Take the concentration of disinfectant as an example, they [healthcare workers] may think that higher concentration is safer, just like protection level, they would rather upgrade than downgrade. So authoritative rules and requirements [usage specifications] were required at that time. (Participant 1)
Some participants mentioned special materials, such as use of contaminated area telephones:
When you put on secondary protection [without a phone], it's definitely not going to work, so you have a contaminated area telephone ready…Now that the status quo is 5G era, robots may be used to replace some human work in the future. (Participant 1)
Four emergency management phases emerged from data analysis: Reduction, Readiness, Response and Recovery, which can be summarized as 4R. The four phases are not only independent of each other, but also related to each other, which is a dynamic system cycle process.
Reduction refers to mitigation, which focuses on the reduction of losses or risks resulting from events and the control of anticipated damages. This phase of activities may take place before, during, or after the event (Rose et al., 2017). In this study, reduction mainly means reducing opportunity and harmfulness of PHEs, including not only prediction, prevention and preparation before PHEs, but also assessment, control and prevention after PHEs. In case of personnel training, the core of Reduction is to review and assess training needs in previous and current (after Recovery) emergencies and to revise training programs, including training time and methods.
Knowledge of infectious diseases needs to be mastered, so we should do something to train nurses to master the most basic protection [knowledge and skills] in the future. In addition, we should not relax at all times in medical work. (Participant 7)
Readiness phase takes place just before an event occurs, and focuses on building or maintaining personnel, systems and infrastructure capacity, and planning, training and exercise necessary to improve emergency response capacity (Rose et al., 2017). This study, mainly refers to preparation work done before PHEs, including preparation from aspects of the 5S, purpose of which is to strengthen the ability of nursing organizations to respond to emergencies. Taking emergency training as an example, the core of Readiness is to organize training, education, exercises, desktop exercises and emergency exercises to deal with PHEs.
They [Emergency team members] had to receive several aspects of training every month, not only study of routine knowledge of several major infectious diseases, but also contents of surrounding epidemic situation…Training involved drills, held quarterly. If this season it's for digestive tract [diseases], next season it's for respiratory infections. Whatever the drill is, it's based on the highest‐level, most serious infectious disease. (Participant 1)
Response occurs after the event, when there is a recognition of a danger that could overwhelm everyday functions or abilities (Rose et al., 2017). Response refers to the response of nursing organizations to PHEs from all aspects. Correct judgement and timely response of nursing organizations are very important at this phase, which also depends on efforts made in the early phase of Reduction and Readiness. Take Human resource deployment as an example, the core of Response phase is establishment of emergency response teams, rapid targeted training and rapid response.
We urgently adjusted manpower structure, mainly from internal medicine, respiratory medicine, neurology, etc… We pulled out the nurses, divided them into echelons, and quickly set up isolation wards. (Participant 6)
Recovery occurs during and after the reaction and involves trying to recover or adjust to a “new” normal after the event (Rose et al., 2017). In the results of this study, mainly refers to the arrangements made by nursing organizations from various aspects and the induction and summary of related aspects after PHEs. The core of Recovery is the combination of peacetime and wartime emergency management, from emergency response to normal operation.
When there are fewer patients on their side [in isolation ward], I allocate the nurses [back to the original wards]. I focus on the number and workload of patients every day, and gradually rotate them out. (Participant 1)
The four stages of NEMS in this study are similar to the emergency management cycle, also with periodicity (Rose et al., 2017). The four stages of emergency management help to describe the capacity and activities of the emergency management system. Each stage contains the corresponding contents of the core elements of 5S and follows the periodic operation of emergency management.
These four phases are independent and interrelated. (1) Reduction focuses on reducing harm losses or risks and controlling expected damages; Activities in this phase can take place before, during, or after PHEs. (2) Readiness activities precede PHEs and focus on building or maintaining personnel, systems and infrastructure capacity, and performing the planning, training and exercises necessary to identify gaps and improve emergency response capacity. (3) Response occurs in recognition of a PHE that threatens to overwhelm day‐to‐day functions or capacities. (4) Recovery phase occurs during and after the response and includes efforts to restore or adapt to “new” normal conditions after PHEs, including efforts to orderly transition response‐related activities to regular public health plans and functions, and capacity‐building efforts to rebuild or strengthen health systems (Rose et al., 2017).
By synthesizing the inner connection and logical relationship of the main themes, a conceptual model was developed (Figure 1 ): the 5S core elements were systematically combined with the 4R phases. In this model, 4R is the outer ring of the model, and the four phases are independent of each other, but also interrelated and influence each other, which is a dynamic system cycle process. As the internal core of the model, 5S represents the core elements of the NEMS for PHEs. This conceptual model shows the NEMS of PHEs with 4R as the management process orientation and 5S as the management dimension, which is a full‐stage closed‐loop management of “Reduction‐Readiness‐Response‐Recovery‐Reduction” based on 5S elements.
Nursing emergency management model.
This study explores NEMS under PHEs from the perspective of nursing administrators who have worked in emergency management of COVID‐19 outbreak. The findings highlight the specific content of the core elements of NEMS and the basic process of NEMS, and finally develop a conceptual model for NEMS.
Findings suggest that most administrators would carry out emergency management work by establishing an organizational structure, usually a three‐tier Organization Structure (Director of the nursing department – Chief head nurse – Head nurse), which is a representative nursing management system in China (Feng et al., 2021). Findings also indicated that cooperation and collaboration played an important role in emergency management. The COVID‐19 pandemic involved collaboration between state, provincial and municipal hospitals, patient transport, manpower deployment and the opening of alternative care sites (CDC, 2020; Oregon Center for Nursing, 2020). Hospital nursing administrators and administrators from other functional departments took various measures to ensure inter‐institutional connectivity (Chen, Du, et al., 2020; Chen, Yang, et al., 2020). In addition, the surge in patients with severe illness and the sudden emergence of healthcare services posed challenges to the construction of nursing workforce in some key specialties, including critical care, Continuous renal replacement therapy (CRRT) care, and psychological care. This is consistent with the findings of studies from the United States and Italy (Bambi et al., 2020; George Washington University, 2021; Imbriaco & Scelsi, 2021). The COVID‐19 pandemic has increased the demand for critical care and the use of complex and invasive life support technologies such as Extracorporeal Membrane Oxygenation (ECMO) and CRRT, increasing the demand for critical care CRRT and infectious disease care. In the case of manpower shortage, the use of nursing students in California during the surge of COVID‐19 cases could supplement the medical staff (California Board of Registered Nurses, 2020), which was not found in this study, and the hospitals in the study were able to coordinate the tasks of registered nurses.
In terms of the management cycle, findings highlight the importance of anticipatory work before the outbreak of the epidemic, such as building up a nursing manpower pool for reservation in advance. This sense of foresight may have benefited from the experience gained from previous emergency management experiences such as SARS and earthquakes. Plans should be in place before an emergency response is launched, and they should be comprehensive, intersectoral and supported by global coordination (Sachs et al., 2022). Other studies have also pointed out the importance of pre‐outbreak preparedness, particularly in terms of training, including basic emergency preparedness, infectious disease knowledge, and leadership education and training (Corless et al., 2018; Veenema et al., 2017; Wakefield et al., 2021). Due to the specific characteristic of the COVID‐19 epidemic, which reoccurs around the world from time to time, the combination of “peacetime” and “wartime” management, and “regular epidemic prevention and control management” have also become key words for emergency management in recovery phrase from the findings.
The shift and reallocation of resource requirements are necessary when shifting from a routine state of medical work to an overload situation where surge capacity is required (Barbisch & Koenig, 2006; Rose et al., 2017). Findings highlight the five core elements of NEMS, three of which are consistent with the essential elements of surge capacity: equipment (Supply), personnel (Staff), and facilities (Structure) (Barbisch & Koenig, 2006; Kaji et al., 2006; Schultz & Koenig, 2006). Meanings of Staff, Supply and Setting in this study are similar to Staff, Supply and Structure in Surge Capacity concept, which refers to human resources, supplies, equipment, all types of personnel, facilities, and programs (Sheikhbardsiri et al., 2017). However, Structure and System are two crucial elements deliberately highlighted in this study as they lead the directions of the other 3Ss with a broader and systematic view of integrating every aspect of nursing.
Structure represents the organizational structure, the synergy of the system, and the command (Reilly & Markenson, 2010). Centralized leadership, efficient operation, and unified dispatch of the nursing management system are important for effective response to PHEs. Attitudes and intentions are direct factors influencing nurses' behaviour during the pandemic, which may be related to a safe working environment, adequate protective equipment, appropriate incentives and correct professional values, which are also in the scope of the ‘structure’ in this study (Nie et al., 2022). With limited information and unpredictable tasks, front‐line nurses were suffering from great physical and psychological stress, and social stigma (Joo & Liu, 2021; Wahed et al., 2020), therefore, physical and psychological support from the perspective of organization were emphasized by most participants. Many of them expressed concern about bringing the virus home to their families, often either staying elsewhere, such as hotels or colleagues' homes, or sleeping in a separate room at home (Grey Ellis, 2020). Some participants in this study also mentioned providing nurses with dietary, accommodation, family and social support.
Psychological stress is also a serious issue among nurses, with the incidence of suicidal ideation reported to be between 3.6% and 8.4% during the COVID‐19 pandemic, and psychological support is particularly important (Smallwood et al., 2022). Different from other studies in which psychological issues were often ignored by superiors during the COVID‐19 pandemic (Nie et al., 2022), psychological support measures were mentioned by most administrators in this study, reflecting their attention to the psychological situation of employees. Interestingly, Marvel Comics teamed up with the Allegheny Health Network to create comics about nurses working tirelessly and courageously like heroes, to raise awareness of what nurses do during the pandemic and promote the role of nurses to younger audiences as an external factor that gives moral support to nurses worldwide (Marvel, 2020).
System is a strategically oriented element that includes policies, principles, systems, and processes. The development of targeted and competent guidelines and operating procedures are important to ensure effective control of PHEs (Wakefield et al., 2021), which is consistent with the value of the “system”. In the context of the COVID‐19 pandemic, front‐line nurses are perceived with heavy workloads and unpredictable challenges due to the lack of PPEs, potentially infected patients, and so on (Joo & Liu, 2021). Therefore, establishing process norms and, improving regulations and emergency plans are critical to ensure strong command, coordination, and effective control of emergency response.
PHEs usually follow a specific life cycle with their own routine of occurrence, development and mitigation, which requires different emergency measures (Coombs, 2011). Findings highlight four phases of NEMS, which correspond to the four periods of the crisis management model: Reduction, Readiness, Response, and Recovery (Heath & Management, 1998). The cycles in previous studies on emergency management are also consistent with the findings of this study, including: Emergency Management Cycle (All About People, 2017; McLoughlin, 1985), Public Health Emergency Preparedness “Mitigation‐Preparedness‐Response‐Recovery” cycle (Nelson et al., 2007), and Emergency Management “Prevention‐Preparedness‐Response‐Recovery” cycle (Resilient Community Organisations, 2015). However, the definitions of four phases in this study are different as they are interpreted and revised because of the specialty of nursing. Reduction and Readiness phases happen before PHEs. The key to “Reduction” is ability to review, reassess, and revise the whole emergency management process, while the key to “Readiness” is ability to prepare for early warning. Response and Recovery phases occur after PHEs. The key to “Response” is ability to act and deploy quickly while the key to “Recovery” is ability to early restorative of normal routine. In the context of recurrent outbreaks of COVID‐19 epidemic (Azam et al., 2020; Sotoodeh Ghorbani et al., 2021), administrators should move from thinking about normal healthcare operations to routine and surge reinforcements for PHEs. Therefore, emergency management will need to shift flexibly to meet demand, and timelines and resource allocation will change. The event is likely to start and move quickly before there is any awareness of it. Rapid response is therefore required through the four phases of NEMS, which sometimes need to be intertwined and repeated (Rose et al., 2017).
The pandemic has also boosted the development of online video conferencing, telemedicine and Virtual Reality teaching technologies. The use of the Internet and mobile applications will improve the efficiency of emergency management. Several applications and software have been developed and operating worldwide since the outbreak. An application called “COVID‐19 Symptom Research” was being widely used in the United Kingdom and the United State to record symptoms, and for health workers (Nguyen et al., 2020 ). Telehealth services are also growing rapidly. At the Cleveland Clinic, about 200 nurses are now providing telehealth care services, from symptom monitoring to patient education, as part of the COVID‐19 emergency response (Cleveland Clinic, 2020).
Due to the epidemic and time reason, this study is still in progress and future work is required to further clarify the key tasks of the 5S elements corresponding to the 4R phases, to identify the specific tasks to be accomplished in each phase and the interactions between the 5S elements and 4R phases. Another limitation of this study is the small sample size. The sample size is relatively small, but it is moderate for this qualitative study as the data and contents needed to enrich the framework was saturated. Most of the Participants are from Grade III COVID‐19 designated hospitals in China, so the proposed conceptual definition might be limited to some degree. The situations of PHE and emergency management strategies might be different in other geographical areas, so the conceptual model may not be adopted directly in other countries as the study was conducted in only one geographical area. Besides, selection bias may exist because the participants had unique experiences and interests in this concept.
Nowadays, with the increasing frequency of PHEs, nurse administrators are faced with great pressures and challenges. Most of nursing administrators generally relied on hospital's command for emergency management in the past. This study provides a referable and practical NEMS model from perspectives of nursing administrators highly involved in COVID‐19 emergency management.
This study defines the five core elements of the model (5S) and the four interrelated and cyclical management phases (4R), and realizes the combination of cycle management and core elements, thus developing a complete NEMS model based on the nursing management practice during the whole COVID‐19 epidemic from nursing administrators. The 5S*4R model provides nursing administrators with management strategies to coordinate and allocate critical resources and define management priorities to meet emergency surges in demand in addition to routine needs, which also enriches the theoretical concepts of NEMS, and provides a perceptive of NEMS from the experience of China. The broad and far‐reaching consequences of the pandemic and other crises urgently call for global nursing administrators to be well‐prepared for how to better respond to future PHEs from their own standings.
Yan Jiang and Ruixue Zhang contributed to the conception and the design of the research; Ruixue Zhang and Congyu You carried out the research design, interview and data analysis; Ruixue Zhang completed the manuscript writing; Lei Wang made important contributions to the research design and manuscript writing; Lingxiao He and Cong Wang made contributions to the research design and interview guideline. Fengjiao Chen, Yujia Huang and Hui Han transcribed the data.
National Natural Science Foundation of China (Grant/Award Number: 72174135); Nursing Research Project of Sichuan Province (Grant/Award Number: NO. H21011). Science and Technology Project of COVID‐19 of Chengdu Science and Technology Bureau (Grant/Award Number: 2020‐YF05‐00028‐SN).
All authors declare no conflicts of interest.
Participants in the study were voluntary and completed informed consent forms. Interviews were recorded with participants’ permission. Research ethics permission was obtained from the Biomedical Ethics Committee of Sichuan University (Approval Number: REDACTED).
We would like to acknowledge the support given by all the funders of this study in ensuring its successful undertaking. We also thank all the support of all the nursing administrators who participated in this research.
Zhang, R. , You, C. , Wang, L. , Jiang, Y. , He, L. , Wang, C. , Chen, F. , Huang, Y. , & Han, H. (2023). A practice‐based nursing emergency management system model for public health emergencies: A descriptive qualitative study . Nursing Open , 10 , 3774–3786. 10.1002/nop2.1635 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
The data that support the findings of this study are available upon request by contact with corresponding author.
