Preventing the dysfunction of public health centres responding to COVID-19 by focusing on public health nurses in Japan

Experience and Resilience of Japanese Public Health Nurses during the COVID-19 Pandemic and Their Impact on Burnout

Japanese public health nurses (PHNs) at public health centers (PHCs) have played critical roles in infection prevention and control during the COVID-19 pandemic. This study aimed to examine the actual pandemic-related experiences of PHNs and the relation between their experiences, individual resilience, two components of organizational resilience (system and human resilience), and burnout. An analysis of the responses of 351 PHNs revealed that mid-level PHNs scored higher in experience and lower in organizational resilience compared with those in other positions. More than 80% of respondents experienced inappropriate staff allocation. Multiple regression revealed that burnout was positively associated with the components of the experience of PHNs and negatively with individual and human resilience. In hierarchical multiple regression with depersonalization as the dependent variable, the sign of system resilience reversed from negative to positive when human resilience was added. The results highlight the need to prepare for future health crises including establishing a system with enough personnel, promoting human resilience such as collaboration among staff members, and burnout prevention measures, especially among mid-level PHNs. The study also described alternative approaches to comprehend system resilience-namely, a suppression variable of human resilience, promotion of depersonalization, and multicollinearity-and the need for further research on organizational resilience.

The Wounded Healer: A Phenomenological Study on Hospital Nurses Who Contracted COVID-19

Since the pandemic began nurses were at the forefront of the crisis, assisting countless COVID-19 patients, facing unpreparedness, social and family isolation, and lack of protective equipment. Of all health professionals, nurses were those most frequently infected. Research on healthcare professionals' experience of the pandemic and how it may have influenced their life and work is sparse. No study has focused on the experiences of nurses who contracted COVID-19 and afterwards returned to caring for patients with COVID-19. The purpose of this study was therefore to explore the lived personal and professional experiences of such nurses, and to describe the impact it had on their ways of approaching patients, caring for them, and practicing their profession. A phenomenological study was conducted with 54 nurses, through 20 individual interviews and 4 focus groups. The main finding is that the nurses who contracted COVID-19 became “wounded healers”: they survived and recovered, but remained “wounded” by the experience, and returned to caring for patients as “healers,” with increased compassion and attention to basic needs. Through this life-changing experience they strengthened their ability to build therapeutic relationships with patients and re-discovered fundamental values of nursing. These are some of the ways in which nurses can express most profoundly the ethics of work done well.

Feasibility of an educational program for public health nurses to promote local healthcare planning: protocol for a pilot randomized controlled trial

BACKGROUND

Promoting of local healthcare planning is crucial for assisting public health nurses in improving community health inequities. However, there is no effective educational program for developing relevant skills and knowledge among these nurses. Therefore, this study aims to assess the feasibility of a newly developed web-based self-learning program to promote the involvement of public health nurses in the local healthcare planning process.

METHODS

A pilot randomized control trial randomly allocated eligible public health nurses to intervention and control wait-list groups [1:1]. The former will be exposed to six web-based learning modules from July to October 2021. After collecting post-test data, the wait-list group will be exposed to the same modules to ensure learning equity. The primary outcome will be evaluated by implementing a validated and standardized scale designed to measure public health policy competencies at the baseline and post-intervention, while secondary outcome will be measured on an action scale to demonstrate the necessity of healthcare activities. The third outcome will be the knowledge and skills related to local healthcare planning by public health nurses. The participants will provide feedback through free descriptions on the trial feasibility and a web-based self-learning program to identify improvement points for continual refinement.

DISCUSSION

The results will provide suggestions in preparation for a future definitive randomized controlled trial. This will provide preliminary data for an intervention aimed at improving relevant competencies among public health nurses who are tasked with resolving health inequities in their respective communities through local health planning.

TRIAL REGISTRATION

The protocol for this study was registered with the University Hospital Medical Information Network Clinical Trials Registry and approved by the International Committee of Medical Journal Editors (No. UMIN000043628 , March 23, 2021).

Number of public health nurses and COVID-19 incidence rate by variant type: an ecological study of 47 prefectures in Japan

Background

Community health activities by public health nurses (PHNs) are known to improve lifestyle habits of local residents, and may encourage the practice of infectious disease prevention behaviors during the COVID-19 pandemic. We investigated the association between prefecture-level COVID-19 incidence rate and the number of PHNs per population in Japan, by the COVID-19 variant type.

Methods

Our data were based on government surveys where prefectural-level data are accessible to the public. The outcome variable was the COVID-19 incidence rate (i.e., the cumulative number of COVID-19 cases per 100,000 population for each variant type in 47 prefectures). The explanatory variable was the number of PHNs per 100,000 population by prefecture. Covariates included socioeconomic factors, regional characteristics, healthcare resources, and health behaviors. The generalized estimating equations of the multivariable Poisson regression models were used to estimate adjusted incidence rate ratio (IRR) and 95% confidence interval (CI) for the COVID-19 cases. We performed stratified analyses by variant type (i.e., wild type, alpha variant, and delta variant).

Results

A total of 1,705,224 confirmed COVID-19 cases (1351.6 per 100,000 population) in Japan were reported as of September 30, 2021. The number of PHNs per 100,000 population in Japan was 41.9. Multivariable Poisson regression models showed that a lower number of PHNs per population was associated with higher IRR of COVID-19. Among all COVID-19 cases, compared to the highest quintile group of the number of PHNs per population, the adjusted IRR of the lowest quintile group was consistently significant in the models adjusting for socioeconomic factors (IRR: 3.76, 95% CI: 2.55–5.54), regional characteristics (1.73, 1.28–2.34), healthcare resources (3.88, 2.45–6.16), and health behaviors (2.17, 1.39–3.37). These significant associations were unaffected by the variant type of COVID-19.

Conclusion

We found that the COVID-19 incidence rate was higher in prefectures with fewer PHNs per population, regardless of the COVID-19 variant type. By increasing the number of PHNs, it may be possible to contain the spread of COVID-19 in Japan and provide an effective human resource to combat emerging infectious diseases in the future.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1265/ehpm.22-00013.

Changes in the Number of Public Health Nurses Employed in Local Governments in Japan During the Covid-19 Pandemic: A Cross-Sectional Study

Introduction

Prefectural public health centers in Japan conducted epidemiological surveys of all COVID-19 patients, which subsequently increased their workload as the infection rate increased. The survey was conducted by public health nurses (PHNs); therefore, an increase in their workload was expected. However, changes in the number of PHNs have not yet been examined. This study focused on recruiting PHNs to local governments in Japan during the COVID-19 pandemic.

Methods

This cross-sectional study of 150 local government public health centers was conducted from November to December 2021. The survey items included the number of full-time and part-time PHNs, number of PHNs who resigned or retired from the job, and number of PHNs recruitment examinations conducted between 2017 and 2021. For all variables, the mean, standard deviation, and minimum and maximum values for each municipality and year were calculated, and a one-way analysis of variance was performed.

Conclusion

The response rate of the questionnaires was 54.0% (81/150). The change in the employment status of PHNs from 2019 to 2020 was not statistically significant in 2020, which was the COVID-19 outbreak year. However, the number of full-time PHNs increased by 2.6, while part-time PHNs almost doubled from 5.2 ± 8.3 to 10.8 ± 9.6 ( p = .61) for prefectures, from 13.6 ± 13.1 to 21.5 ± 34.8 ( p = .23) for cities, and from 16.8 ± 26.8 to 52.3 ± 132.5 ( p = .70) for wards. The survey revealed that since the COVID-19 pandemic, the ratio of part-time to full-time PHNs significantly increased. Current status reports of public health centers will encourage political decisions and research on the factors necessary to balance the supply and demand of full-time PHNs.

Content Analysis of the Free COVID-19 Telephone Consultations Available during the First Wave of the Pandemic in Japan

This cross-sectional study aimed to (1) describe the unclassified contents of telephone consultation services provided by a public health center during the first wave of COVID-19 in Japan and (2) examine whether the contents required assistance from public health nurses (PHNs). We analyzed a total of 207 calls in which the purpose of the call was unclassified into pre-set categories. PHNs transcribed the exact text of the consultation conversations recorded from 25 March to 20 April 2020 in City A. Approximately half of the calls were from residents. Seven categories were extracted through a qualitative content analysis. The most common topic was infection control measures, where the presence of COVID-19 infection was assumed (n = 62); the second most common was extreme anxiety and fear of infection (n = 50). Questions about the COVID-19 response system (n = 30), discrimination and misunderstandings about COVID-19 (n = 24), and response measures for COVID-19 outbreaks within organizations (n = 18) were also included. The unclassified consultations included various topics, several of which required the expertise of a PHN. Each local government should consider sharing and task-shifting telephone consultation services among PHNs and other staff to reduce their burden and allow them to concentrate on conducting infection control more effectively.

Confusions and responses of managerial public health nurses during the COVID-19 pandemic in Japan

Objective

This study aimed to elucidate the experiences of public health nurses (PHNs) in Japan during the first wave of COVID‐19.

Design and sample

Twelve PHNs in charge of responding to COVID‐19 in X‐city within Tokyo metropolis in Japan participated in this case study.

Measurements

Data were collected through self‐administered questionnaires and semi‐structured interviews on PHNs’ experiences from January 2020 to May 2020.

Results

Initially, only infectious disease control division (IDCD) PHNs experienced confusion due to the rapidly increased workload. Managerial PHNs attempted to explain the need for a dispatch system for the IDCD, using available statistical data from other managerial members, within one's maximum understanding of this unprecedented situation. Without having a clear and forward‐looking understanding regarding the purpose and reasons for dispatching, some dispatched PHNs had concerns and frustrations; they did not view the COVID‐19 pandemic as a disaster. In the never‐ending, exhausting work, PHNs managed to modify the provision of conventional services to residents.

Conclusions

Despite experiencing confusion, PHNs worked to continuously provide community services, re‐considering the meaning of public health nursing. Prioritizing the work and shifting tasks to other professionals at an early stage of the pandemic may prevent organizational dysfunction.

Characteristics of COVID-19-Related Free Telephone Consultations by Public Health Nurses in Japan: A Retrospective Study

This study aimed to (1) describe the characteristics of community residents who used coronavirus disease 2019 (COVID-19)-related telephone consultation systems by public health nurses (PHNs) and (2) analyze the concerns they had during the first wave of COVID-19 in Japan. Among 1126 telephone consultations, PHNs recorded telephone consultations between 25 March, and 30 April, 2020, in City A, Japan. We analyzed 1017 consultations involving 799 (79%) community residents (resident group) and 218 (21%) organizational representatives (organization group) located in City A. Half of the consultations were made during midmorning, and most of the consultations were regarding COVID-19 symptoms. Among the resident group, visiting a primary care doctor was the most common recommendation by the PHNs; there was no difference in provision of consultation by sex. Health- and welfare-related organizations mainly consulted PHNs about "having COVID-19-related symptoms" and "undergoing PCR testing," and PHNs' recommended them to visit a primary care doctor and coordinate PCR testing. The results suggest that public health centers should provide more helpful information on COVID-19 that accurately reflects the concerns of the population.

Covid-19 Preparedness and Response Capability: A Case Study of the Hanoi Primary Healthcare System

This study examined the coronavirus disease 2019 (COVID-19) preparedness and response of the health system (HS) in Hanoi, Vietnam, and identified enabling factors and barriers. This cross-sectional, mixed-methods study was conducted in 4 urban and peri-urban districts that included some wards with COVID-19-positive cases and some without. The US Centers for Disease Control and Prevention (CDC) analytical frameworks were used. Overall, 10% of health facilities (HFs) failed to fully implement COVID-19 risk determination; 8.8% failed to fully implement stronger community partnerships with local stakeholders to support public health (PH) preparedness; 35% and 2.5% incompletely implemented and did not implement evaluation of PH emergency operations, respectively; 10% did not identify communication channels to issue public information, alerts, warnings, and notifications; 25% incompletely implemented identification, development of guidance, and standards for information; 72.5% had good preventive and treatment collaboration; and 10% did not fully implement procedures for laboratory testing and reporting results. Enablers included sufficient infrastructure and equipment, strong leadership, and good cross-public-sector collaboration with police and military forces. Barriers included workforce constraints, overburdened and inconsistent reporting systems, inappropriate financial mechanisms, ambiguous health governance, and lack of private-sector engagement. Nonetheless, the HS preparedness and response were satisfactory, although further coordinated efforts in evaluation, coordination, communication, and volunteering remain necessary.

A mixed methods study of an organization's approach to the COVID-19 health care crisis

Background

Healthcare emergency can increase work-related stress and reduce nurses’ job satisfaction and quality of life. Managerial decisions and proactive interventions implemented to react to the emergency ensure the best patient outcomes.

Purpose

The purpose of this study was to verify whether a proactive organizational approach can limit nurses’ work-related stress and help preserve their job satisfaction and quality of life during a health emergency.

Methods

A longitudinal mixed methods study was conducted. Data were collected before and after the transformation into a SARS-CoV-2 Hospital and the implementation of organizational interventions. Focus groups were conducted to investigate quantitative data.

Findings

After the implementation of interventions and as the pandemic progressed, work-related stress decreased and job satisfaction and quality of life increased.

Discussion

Through proactive organization, even during an emergency, nurses are prepared for working, and work-related stress due to changes is reduced. Nurses are motivated and satisfied with their organization and management, and quality of life increases.

Developing sustainable public health care systems for responding to COVID-19 in Japan

OBJECTIVE

Despite having prevented public health center (PHC) dysfunction in response to COVID-19 during the first wave, public health nurses (PHNs) who play a central role in preventing COVID-19 and supporting community people were unable to share practical knowledge with other PHNs immediately. This report aims to introduce the development of novel sustainable public health care systems with regard to COVID-19 in Japan: task sharing, securing staff, and task shifting.

METHODS

A descriptive study. The Japan Ministry of Health, Labour, and Welfare enlisted good practices regarding resource allocation and developing full readiness for sustainable public health care systems in September 2020.

RESULTS

Public health center developed systems for office support, infection control, hospital coordination, and outsourced inventory control. To reduce the workload of PHNs, a support team of three to four office workers developed a response manual for residents and a format for telephone consultations regarding COVID-19. Developing an infection control team and web-based system for hospital coordination decreased the workload of PHCs in each community to prepare for the pandemic.

CONCLUSION

Public health center should consider managing limited human resources and focus on providing specialized care for COVID-19 patients. Task sharing, securing staff, and task shifting are crucial strategies for developing sustainable public health care systems.

Proposal of COVID-19 Clinical Risk Score for the management of suspected COVID-19 cases: a case control study

BACKGROUND

No clinical scoring system has yet been established to estimate the likelihood of coronavirus disease (COVID-19) and determine the suitability of diagnostic testing in suspected COVID-19 patients.

METHODS

This was a single-center, retrospective, observational study of patients with suspected COVID-19 and confirmed COVID-19. Patient background, clinical course, laboratory and computed tomography (CT) findings, and the presence of alternative diagnoses were evaluated. Clinical risk scores were developed based on clinical differences between patients with and without COVID-19.

RESULTS

Among 110 patients suspected of having COVID-19, 60.9% underwent polymerase chain reaction (PCR) testing based on the judgment of physicians. Two patients were found to have COVID-19. The clinical characteristics of 108 non-COVID-19 patients were compared with those of 23 confirmed COVID-19 patients. Patients with COVID-19 were more likely to have a history of high-risk exposures and an abnormal sense of taste and smell. The COVID-19 group had significantly higher rates of subnormal white blood cell counts, lower eosinophil counts, and lower procalcitonin levels than the non-COVID-19 group. When blood test results, CT findings, and the presence of alternative diagnoses were scored on an 11-point scale (i.e., "COVID-19 Clinical Risk Score"), the COVID-19 group scored significantly higher than the non-COVID-19 group, more than four points in the COVID-19 group. All non-COVID patients who did not undergo PCR had a score of 4 or less.

CONCLUSIONS

The COVID-19 Clinical Risk Score may enable the risk classification of patients suspected of having COVID-19 and can help in decision-making in clinical practice, including appropriateness of diagnostic testing. Further studies and prospective validation with an increased sample size are required.