'Your country needs you': the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19

Adapting, restarting, and terminating a randomised control trial for people with cystic fibrosis: Reflections on the impact of the COVID-19 pandemic upon research in a clinical population

Background

Habitual physical activity (PA) and exercise form a cornerstone of the management of cystic fibrosis (CF), a genetically inherited pulmonary and digestive condition - whereby telehealth platforms have been proposed as a mechanism to engage remotely people with CF in PA and exercise.

Methods

To test this, in early 2020, the 'ActivOnline: Physical Activity in Cystic Fibrosis Trial' (ActiOn PACT) randomised control trial was established to examine whether an online intervention was effective at increasing PA in adolescents and adults with CF.

Results

The emergence of the COVID-19 pandemic in 2020 forced this trial to be paused and modified, with the adoption of online recruitment and remote assessment of outcome measures. Despite such adaptations in accord with frameworks developed by the National Institute for Health Research, this trial failed to recruit and was subsequently terminated.

Conclusions

This article details the authors reflections upon the proposed reasons for lack of recruitment, including improved technology and medications for people with CF, and contextualises this finding in relation to the wider issue of non-reporting of trial results in clinical research.

Should I Help? Prosocial Behaviour during the COVID-19 Pandemic

The Movement Control Order (MCO) enacted during the COVID-19 pandemic has profoundly altered the social life and behaviour of the Malaysian population. Because the society is facing huge social and economic challenges that need individuals to work together to solve, prosocial behaviour is regarded as one of the most important social determinants. Because it is related with individual and societal benefits, participating in prosocial activities may be a major protective factor during times of global crisis. Rather than focusing only on medical and psychiatric paradigms, perhaps all that is necessary to overcome the COVID-19 risks is for individuals to make personal sacrifices for the sake of others. In reality, a large number of initiatives proven to be beneficial in decreasing viral transmission include a trade-off between individual and collective interests. Given its crucial importance, the purpose of this concept paper is to provide some insight into prosocial behaviour during the COVID-19 period. Understanding prosocial behaviour during the COVID-19 pandemic is crucial because it may assist in the establishment of a post-COVID society and provide useful strategies for coping with future crises.

Relationship between nursing students' attitudes toward nursing profession and online learning satisfaction during COVID-19 lockdown

Formal education is crucial for the development of nurses’ professional identity and can play a decisive role in attracting students to the nursing profession. This is even more important during a public health emergency such as the COVID-19 pandemic. This study aimed to investigate nursing students’ attitudes and feelings toward their future profession and academic studies during the first COVID-19 lockdown. A cross-sectional, descriptive study was conducted on 361 nursing students. The data were collected through the Students’ attitudes toward the nursing profession during the COVID-19 outbreak scale, and the Satisfaction with online learning scale. Nursing students expressed higher levels of commitment and dedication to their profession compared to perceived job security. They were generally satisfied with their distance learning experience in terms of accessibility of study materials, adaptation of lectures and quality of communication with academic staff. However, students perceived the ICT-supported distance learning as moderately effective. Students’ satisfaction with online learning was positively related to their perceived professional commitment. In times of health crisis, faculties should consider students’ perceived quality of nursing education and attitudes toward future profession to promote appropriate professional identity.

Experiences of redeployed healthcare workers in the fight against COVID-19 in China: A qualitative study

Introduction

Public health responses were triggered while COVID-19 was spreading. China redeployed healthcare workers to serve the most vulnerable populations and communities in the initial epicentre—Wuhan. However, it is not known how redeployment processes impacted on healthcare workers in a pandemic crisis.

Aims

To explore the experiences and needs of frontline healthcare workers who were redeployed to care for COVID-19 patients in Wuhan, China, and understand the long-term impacts of the redeployment experience on their work and life.

Methods

A qualitative study was conducted with redeployed healthcare workers using semi-structured interviews and thematic analysis. This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines.

Findings

A total of 20 redeployed healthcare workers (13 nurses and seven physicians) participated, and four themes were generated: (1) Initial feelings and emotions of redeployment—Participants experienced worries and concerns, a sense of isolation and loneliness on their arrival to the epicentre. (2) ‘It is like a war zone’—Healthcare workers faced a range of risks and challenges of caring for COVID-19 patients in Wuhan in the context of resource strain. (3) Uncertainty and coping strategies in patient care—Despite the hardships experienced, participants continued to deliver high-quality patient care including psychological care and palliative care, good communication and building mutual trusting relationships. (4) Reflection and far-reaching impacts of caring for COVID-19 patients—Participants felt motivated and encouraged as efforts were recognised by the government and wider society.

Conclusions

Redeployed healthcare workers shared their unique needs and experiences of coping with redeployment and challenges they faced in the context of resource strain, which has significant implications for policy and future practice. The reality of a pandemic may reduce healthcare workers’ willingness to work due to various reasons including inadequate preparedness of facilities and workplace safety. It is important to support frontline healthcare workers in order to maintain an adequate healthcare workforce in pandemic crises. Continuously evolving pandemic circumstances and uncertainty highlight the importance of an organized national pandemic response plan for subsequent waves of COVID-19 and future pandemics.

Polarized Citizen Preferences for the Ethical Allocation of Scarce Medical Resources in 20 Countries

Objective. When medical resources are scarce, clinicians must make difficult triage decisions. When these decisions affect public trust and morale, as was the case during the COVID-19 pandemic, experts will benefit from knowing which triage metrics have citizen support. Design. We conducted an online survey in 20 countries, comparing support for 5 common metrics (prognosis, age, quality of life, past and future contribution as a health care worker) to a benchmark consisting of support for 2 no-triage mechanisms (first-come-first-served and random allocation). Results. We surveyed nationally representative samples of 1000 citizens in each of Brazil, France, Japan, and the United States and also self-selected samples from 20 countries (total N = 7599) obtained through a citizen science website (the Moral Machine). We computed the support for each metric by comparing its usability to the usability of the 2 no-triage mechanisms. We further analyzed the polarizing nature of each metric by considering its usability among participants who had a preference for no triage. In all countries, preferences were polarized, with the 2 largest groups preferring either no triage or extensive triage using all metrics. Prognosis was the least controversial metric. There was little support for giving priority to healthcare workers. Conclusions. It will be difficult to define triage guidelines that elicit public trust and approval. Given the importance of prognosis in triage protocols, it is reassuring that it is the least controversial metric. Experts will need to prepare strong arguments for other metrics if they wish to preserve public trust and morale during health crises.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events

Background

Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events.

Methods

Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points.

Discussion

Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).

Experiences and concerns of health workers throughout the first year of the COVID-19 pandemic in the UK: A longitudinal qualitative interview study

OBJECTIVE

To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK.

METHODS

Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis.

RESULTS

We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion.

CONCLUSIONS

Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.

Nursing students’ clinical placement experiences during the Covid-19 pandemic: A phenomenological study

Aim

This study explored the clinical placement experiences of nursing students during the Covid-19 pandemic.

Background

The health emergency caused by Covid-19 required a rapid reorganisation of care settings. This reorganisation entailed revisiting the clinical placements settings and learning programs of Italian nursing faculties. Some Italian universities wanted to seize the health emergency as a learning opportunity enabling the nursing student to acquire additional knowledge and skills.

Design

We conducted a descriptive qualitative study employing a phenomenological approach. The study population was second and third-year nursing students. The students did their clinical placement in 5 Northern Italy hospitals, mainly in infectious diseases wards, intensive care and sub-intensive care units, emergency department, short-stay surgical units and internal medicine wards. In these departments, the inpatient wards were entirely converted into Covid-19 units. Ethical approval was obtained from the local ethics committee.

Methods

Semi-structured, open-ended interviews were conducted in March-April 2021 and analysed following a phenomenological approach.

Results

Twenty-one nursing students in their 2nd and 3rd academic year participated. Their average age was 24 years. 81% were female and 19% were male. Three main themes were generated: (i) Learning which surpasses technicalities; (ii) Confronting dignity issues; (iii) Feeling treated as an equal in the workspace. Students had to learn how to lower their fear and self-manage the emotional burden to be a caring presence for the patients who were intensely suffering from the disease and isolation. Attending a clinical practice placement in Covid-19 wards led them to focus on human dignity issues: participants realised how dignity was questioned and how they could become patients’ advocates. Students also described that they felt part of the team, with their student role almost fading.

Conclusions

This study describes that the most unpredictable public health emergency, such as Covid-19, can provide learning opportunities in the practice environment for nursing students. Students described feeling useful and capitalising on new competencies. Designing educational activities for nursing students concerning pandemic emergencies may be strategic for dealing with similar situations in the future.

Changes in sexual functions and habits of healthcare workers during the ongoing COVID-19 outbreak: a cross-sectional survey study

BACKGROUND

The negative psychosocial effects of the ongoing COVID-19 pandemic on healthcare workers are increasing worldwide.

AIM

The aim of this study is to investigate the impact of healthcare workers' long-term exposure to the COVID-19 outbreak on their sexual habits and functions.

METHODS

A total of 263 healthcare workers completed this online questionnaire between 1 December 2020 and 31 January 2021. After the informed consent of the participants, the first part of the three-part survey included demographic data, COVID-19 disease status and sexual habits before and after COVID-19, sexual function and anxiety status assessment in the second and last part.

RESULTS

A total of 240 participants were included in the study. Of the participants, 124 were men, 116 were women. The mean age of the participants was 40.18 ± 7. Compared to pre-pandemic period, health workers' sexual desire level (p = 0.000), weekly sexual intercourse frequency (p = 0.001), foreplay duration (p = 0.000), and coitus duration (p = 0.009) decreased during the ongoing pandemic period. When the factors affecting sexual dysfunction were evaluated with multivariate logistic regression analysis, it was determined that female gender (OR 0.312), high anxiety score (OR 0.949), and decreased quality social time spent with spouse or partner were risk factors for sexual dysfunction (OR 0.358).

CONCLUSION

Psychological support provided to healthcare workers during the ongoing pandemic period will improve their sexual habits and functions negatively affected by the COVID-19 outbreak, as well as their social life with their spouses or partners.

Perception of healthcare workers towards ethical aspects of responsiveness of COVID 19 outbreak: A cross-sectional study

Introduction:

COVID-19 has spread all over the world and most of the countries are still grappled with the Pandemic. Health-care-workers (HCWs) being the frontlines during such pandemics have different beliefs and faiths with regards to ethical aspects of preparations.

Methodology:

In order to study the perception of HCW about ethical aspects of COVID-19, a cross-sectional study was done in a tertiary-care-teaching hospital. A pretested questionnaire was circulated among the participants on a digital platform.

Results:

The HCWs were divided over many statements, like if COVID-19 was more hype than reality (45.77% disagreed and 43.25% agreed). 57.44% of participants either agreed or strongly agreed that the treatment of non-COVID-19 cases suffered due to arrangements made for COVID-19 cases. When the responses received against individual statements were compared with various other socio-demographic variables as a denominator, various interesting results were revealed. There was a significant difference of opinion among the participating HCWs (P < 0.05).

Conclusion:

Differences of the opinions had their relationships to demographic characteristics of the subjects as well as related to perceived knowledge of COVID-19.

The Effects of COVID-19 Pandemic on Trauma Registry and Performance Improvement Operations and Workforce Nationwide: A Survey of Trauma Center Association of America Members

Background

Trauma Centers integrate Trauma Registrars and Performance Improvement Nurses to drive quality care. Delays in their duties could have negative impacts on outcomes and performance. We aim to investigate the impact of COVID-19 pandemic on Trauma Center operations by assessing performance of trauma registry and performance improvement processes across the United States.

Methods

A cross-sectional study was performed utilizing data from two anonymous questionnaires distributed to Trauma Center Association of America members. Descriptive statistics, Fisher's Exact Test, and multivariable logistic regression were performed with statistical significance defined as P < 0.05.

Results

Of 90.2% (83) of Trauma Registrars and 85.9% (67) of Performance Improvement personnel reported that their Trauma Centers have treated COVID-19 patients. Among trauma registrars, respondents did not significantly differ in the current status of completing registry cases (P> 0.05), during COVID-19 compared to prior (P> 0.05), or adjusted odds of COVID-19 delaying completion of entries (P> 0.05). Having >2 Performance Improvement Nurses was significantly associated with improved performance during the COVID-19 pandemic (P= 0.03) whereas working at a Trauma Center which treats adults-only or mixed patient population (adult and pediatric) was associated with being 1-3 months behind in closing of performance improvement cases (P= 0.02).

Conclusions

The negative impact of COVID-19 on Trauma Registrars and Performance Improvement Nurses has been minimal. Adequate staffing/experience seem to mitigate delays and decreased performance. Implementation of expanded staffing, improved training, and evidenced-based revision of Trauma Center logistics may help mitigate future disruptions relating to COVID-19 and allow Trauma Centers to recover and improve their operations.

Moral Decision-Making in Healthcare and Medical Professions During the COVID-19 Pandemic

With the coronavirus disease 2019 (COVID-19) outbreak, healthcare and medical professions face challenging situations. The high number of COVID-19 infected patients, scarce resources, and being vulnerable to the infection are among the reasons that may influence clinicians’ moral decision-making. Furthermore, healthcare workers may be carriers of coronavirus, resulting in their social interactions to involve moral decision-making. This study aimed to investigate the effect of working in the frontline on psychological and cognitive factors and how these factors influence moral decision-making in clinicians during the pandemic. Further, we evaluated the impact of these factors on compliance with social distancing. Clinicians who worked in hospitals allocated to coronavirus disease patients participated in our study. We designed an online survey containing eight dilemmas to test moral decision-making in clinicians. Information on clinicians’ behavior and psychological state during the COVID-19 pandemic including the degree of respect to social distancing, sources of stress, and dead cases of COVID-19 they confronted with were collected. First, the relation between these measures and moral decision-making was assessed. Next, we used multiple regression analysis to evaluate the degree to which these factors can predict variances in morality. Based on our results, clinicians’ most important source of stress was the infection of their families. Stress, estimated chance of self-infection, job satisfaction, and age predicted utilitarian behavior among them. Moreover, age, number of death cases of COVID-19 they confronted, perceived risk of infection, and stress were positively correlated to compliance with social distancing. Our results have critical implications in implementing policies for healthcare principals.

The impact of the COVID-19 pandemic on the workload, case mix and hospital resources at a tertiary vascular unit

Background

: The aim of this study was to examine the COVID-19 pandemic and its associated impact on the provision of vascular services, and the pattern of presentation and practice in a tertiary referral vascular unit.

Methods

: This is a retrospective observational study from a prospectively maintained data-base comparing two time frames, Period 1(15th March-30th May 2019-P1) and Period 2(15th March-30th May 2020-P2)All the patients who presented for a vascular review in the 2 timeframes were included. Metrics of service and patient care episodes were collected and compared including, the number of emergency referrals, patient encounters, consultations, emergency admissions and interventions. Impact on key hospital resources such as critical care and imaging facilities during the two time periods were also examined.

Results

: There was an absolute reduction of 44% in the number of patients who required urgent or emergency treatment from P1 to P2 (141 vs 79). We noted a non-significant trend towards an increase in the proportion of patients presenting with Chronic Limb Threatening Ischaemia (CLTI) Rutherford 5&6 (P=0.09) as well as a reduction in the proportion of admissions related to Aortic Aneurysm (P=0.21). There was a significant absolute reduction of 77% in all vascular interventions from P1 to P2 with the greatest reductions noted in Carotid (P=0.02), Deep Venous (P=0.003) and Aortic interventions (P=0.016). The number of lower limb interventions also decreased though there was a significant increase as a relative proportion of all vascular interventions in P2 (P=0.001). There was an absolute reduction in the number of scans performed for vascular pathology; Duplex scans reduced by 86%(P<0.002), CT scans by 68%(P<0.003) and MRIs by 74%(P<0.009).

Conclusion

: We report a decrease in urgent and emergency vascular presentations, admissions and interventions. The reduction in patients presenting with lower limb pathology was not as significant as other vascular conditions, resulting in a significant rise in interventions for CLTI and DFI as a proportion of all vascular interventions. These observations will help guide the provision of vascular services during future pandemics.

The impact of providing end-of-life care during a pandemic on the mental health and wellbeing of health and social care staff: Systematic review and meta-synthesis

Background

Disease outbreaks and disasters can result in excess deaths and severe disruption of usual end-of-life care processes. We aimed to: i) synthesise evidence describing the experiences of health and social care staff providing end-of-life care during a disease outbreak or humanitarian disaster, ii) understand the impact on their mental health and wellbeing and, iii) identify means of support.

Methods

A systematic review with meta-synthesis was conducted including studies of health and social care staff providing end-of-life care during disease outbreaks (Ebola, COVID-19, SARs, MERs) or humanitarian disasters (2001–2020). MEDLINE (Ovid), Embase, PsycInfo, Web of Science, and grey literature databases were searched systematically, with forward and backward citation searching of included studies. Any research study designs, in any care settings, were included. Study quality was assessed using an appraisal tool relevant to each study design. Qualitative meta-synthesis was used to analyse the findings, which were then reported narratively. PROSPERO registration: CRD42020181444.

Results

Nineteen studies were included, including 10 Ebola studies and two COVID-19 studies. The analysis generated two superordinate themes: individual experience and organisational responsibilities. Individual experience comprised four themes: dignity in death, positive experiences, negative experience and support for staff. Organisational responsibilities comprised four themes: preparation, adaption, resources, and Personal Protective Equipment (PPE).

Discussion

No studies quantitively measured the impact of providing end-of-life care on staff mental health and wellbeing, however qualitative studies described experiences in varied settings. Serious disease outbreaks and disasters can expose care staff to abnormally high levels of mortality and suffering. Health and social care systems need to proactively prepare for future events and enable peer support mechanisms that may help mitigate experiences of psychological distress in humanitarian crises.

Considerations for acute care staffing during a pandemic

The increase in interconnectedness of the global population has enabled a highly transmissible virus to spread rapidly around the globe in 2020. The COVID-19 (Coronavirus Disease 2019) pandemic has led to physical, social, and economic repercussions of previously unseen proportions. Although recommendations for pandemic preparedness have been published in response to previous viral disease outbreaks, these guidelines are primarily based on expert opinion and few of them focus on acute care staffing issues. In this review, we discuss how working in acute care medicine during a pandemic can affect the physical and mental health of medical and nursing staff. We provide ideas for limiting staff shortages and creating surge capacity in acute care settings, and strategies for sustainability that can help hospitals maintain adequate staffing throughout their pandemic response.

The Impact of the COVID-19 Pandemic on ICU Healthcare Professionals: A Mixed Methods Study

The large numbers of patients admitted to intensive care units due to COVID-19 has had a major impact on healthcare professionals. The incidence of mental health disorders among these professionals has increased considerably and their professional quality of life has suffered during the pandemic. This study aims to explore the impact of the provision of COVID-19 patient care on ICU healthcare professionals. A mixed methods study with an exploratory concurrent design was conducted between June and November 2020 in the Balearic Islands, Spain. Data were collected using a self-report online survey (n = 122) based on three validated questionnaires, and individual semi-structured in-depth online interviews (n = 11). Respondents scored 2.5 out of 5 on the moral distress scale, moderate/high on the compassion satisfaction scale, and moderate on the burnout and compassion fatigue subscales. Age was significantly and negatively related to professional quality of life but was positively related to workload and unavailability of protective equipment. Three main groups of themes relating to the impact of the pandemic emerged from the in-depth interviews: (a) clinical, (b) professional, and (c) personal and family impacts in the two waves. ICU healthcare professionals should be viewed as second victims of the COVID-19 pandemic as they have suffered significant psychological, professional, and moral harm.

An Integrative Review of Team Nursing and Delegation: Implications for Nurse Staffing during COVID-19

Background

During the COVID‐19 pandemic, providing care for critically ill patients has been challenging due to the limited number of skilled nurses, rapid transmission of the virus, and increased patient acuity in relation to the virus. These factors have led to the implementation of team nursing as a model of nursing care out of necessity for resource allocation. Nurses can use prior evidence to inform the model of nursing care and reimagine patient care responsibilities during a crisis.

Purpose

To review the evidence for team nursing as a model of patient care and delegation and determine how it affects patient, nurse, and organizational outcomes.

Methods

We conducted an integrative review of team nursing and delegation using Whittemore and Knafl’s (2005) methodology.

Results

We identified 22 team nursing articles, 21 delegation articles, and two papers about U.S. nursing laws and scopes of practice for delegation. Overall, team nursing had varied effects on patient, nursing, and organizational outcomes compared with other nursing care models. Education regarding delegation is critical for team nursing, and evidence indicates that it improves nurses’ delegation knowledge, decision‐making, and competency.

Linking evidence to action

Team nursing had both positive and negative outcomes for patients, nurses, and the organization. Delegation education improved team nursing care.

Ethical Dimensions of Public Health Actions and Policies With Special Focus on COVID-19

During pandemics, the ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should, at best, be addressed through integrated, global policies. How to rationalize the healthcare resources and prioritize the cases is not a recent challenge but the serious concern about that is how to achieve this while not increasing the vulnerability of the disadvantaged population. Healthcare professionals use different scoring systems as a part of their decision-making so the medical teams and triage committees can allocate resources for predictable health outcomes and prognosis as well as to appropriately triage the patients accordingly. However, the value of the existing scoring systems to manage COVID-19 cases is not well-established yet. Part of this problem includes managing non-COVID patients with chronic medical conditions like non-communicable diseases and addressing their medical needs during the pandemic complex context in a way to avoid worsening their conditions and, on the other hand, avoid hindering the establishment of comprehensive standards for dealing with COVID-19. In this article, we discuss this dilemma as well as how preexisting ethical standards were challenged by COVID-19. We also discuss how monitoring the consistent application of ethical standards during the medical trials of new medications, vaccines, or unproven medical interventions is also a critical issue.

COVID-19 pandemic in São Paulo: a quantitative study on clinical practice and mental health among medical residency specialties

BACKGROUND

2020 was a challenging year for all healthcare professionals worldwide. In São Paulo, Brazil, the virus SARS-CoV-2 took 47,222 lives up to December 29, 2020. The front line of medical professionals in São Paulo was composed of many residents, who were transferred from their rotations to cover the needs of the pandemic.

OBJECTIVE

To identify medical residents' mental health and clinical issues, regarding symptoms of burnout, depression and anxiety during the pandemic, and to compare them among specialties.

DESIGN AND SETTING

Quantitative study using a convenience sample of medical resident volunteers who responded to an anonymous online survey that was available during April 2020.

METHODS

This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout, the Patient Health Questionnaire (PHQ-9) to measure depression and the General Anxiety Disorder (GAD-7) scale to measure anxiety symptoms. This study also developed a COVID-19 Impact Questionnaire (CIQ-19) to assess the residents' beliefs and clinical practices relating to COVID-19 patients.

RESULTS

The sample comprised 1,392 medical residents in São Paulo, Brazil. Clinical specialty physicians showed the highest rates of anxiety symptoms (52.6%) and burnout (51.2%), among the specialties.

CONCLUSION

Clinical specialty residents are at higher risk of anxiety, depression and burnout. The symptoms of anxiety and depression have worsened during the COVID-19 pandemic. There is a general need for mental health support interventions for medical resident physicians, which requires reinforcement during this worldwide crisis.

COVID-19: opportunities for public health ethics?

Public health ethics is the discipline that ensures that public health professionals and policy makers explain what they do, and why. During the COVID-19 pandemic, ethical deliberations often did not feature explicitly in public health decisions, thus reducing transparency and consistency in decision-making processes, and resulting in loss of trust by the general public. A public health ethics framework based on principles would add to transparency and consistency in public health decision-making. A framework of seven principles is presented and illustrated by applying them to vital COVID-19 ethical questions. Next the question of COVID-19 vaccination shows how the principles work in conjunction. In conclusion, embedding explicit ethical analysis in public health work is necessary to be trustworthy and regain trust. Preparedness for future challenges implies making the public health community more 'ethically literate'.

Mental health and the COVID-19 pandemic: a study of medical residency training over the years

OBJECTIVES

This study aims to assess the symptoms of burnout, depression, and anxiety in Brazilian medical residents during the COVID-19 pandemic and to compare residents' beliefs and clinical practices related to COVID-19 patients among all six years of medical residency training in Brazil.

METHODS

A quantitative study was conducted in April 2020 with a convenience sample of medical resident volunteers from an anonymous online survey. This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout, the Patient Health Questionnaire (PHQ-9) to measure depression, and the General Anxiety Disorders (GAD-7) to measure generalized anxiety disorder. This study also developed a COVID-19 Impact Questionnaire (CIQ-19) to assess the residents' beliefs and clinical practices related to COVID-19 patients.

RESULTS

Our sample comprised 3071 respondents. Depressive symptoms were the most common among second-year residents (70.5%), followed by anxiety symptoms (56.0%) and burnout (55.2%) among fourth-year residents. We also observed burnout symptoms (55.1%) among second-year residents.

CONCLUSION

The COVID-19 pandemic increased the risk of mental illnesses in some years of residency. Our study could not conclude the reasons why the incidence varies among levels of physician training. Final year medical residents have avoided seeing COVID-19 patients.

Impact of COVID-19 on Healthcare Workers in Brazil between August and November 2020: A Cross-Sectional Survey

During the COVID-19 pandemic, healthcare workers (HCW) have been subjected to greater workloads. We conducted a cross-sectional online survey to assess the impact of the COVID-19 pandemic on Brazilian HCW. Data were collected between 11 August and 1 November 2020. Of the 295 respondents, 95 (32.2%) were medical doctors, 82 (27.8%) administrative staff, 53 (18.0%) nurses, 27 (9.2%) laboratory staff, and 38 (12.9%) were other staff. COVID-19-related restructuring at the health facilities was reported by 207 (70.2%) respondents, and 69 (23.4%) had their tasks changed. Preventive measures were well respected when seeing suspected patients. Overall, 167 (56.6%) HCW screened positive for anxiety and 137 (46.4%) for depression; 109 (36.9%) screened positive for both conditions. Of the 217 (73.6%) HCW who had been tested for COVID-19, at least one positive result was reported in 49 (22.6%). Following a positive COVID-19 test, 45/49 (91.8%) stopped working and stayed home. In conclusion, we found a high incidence of COVID-19 infection among Brazilian HCW with high rates of anxiety and depression despite a good self-reported adherence to COVID-19 preventive measures. As such, our study highlights the urgent need for interventions to mitigate the psychosocial risks HCW in Brazil encounter during the COVID-19 pandemic.

Stopping exploitation: Properly remunerating healthcare workers for risk in the COVID-19 pandemic

We argue that we should provide extra payment not only for extra time worked but also for the extra risks healthcare workers (and those working in healthcare settings) incur while caring for COVID-19 patients-and more generally when caring for patients poses them at significantly higher risks than normal. We argue that the extra payment is warranted regardless of whether healthcare workers have a professional obligation to provide such risky healthcare. Payment for risk would meet four essential ethical requirements. First, assuming healthcare workers do not have a professional obligation to take on themselves the risks, payments in the form of incentives would preserve autonomy in deciding what risks to take on oneself. Second, even assuming that healthcare workers do have a professional obligation to take on themselves the risks, payments for risk would create fair working conditions by avoiding exploitation. Third, payments for risk would make it more likely that public healthcare systems can discharge their institutional responsibility to provide healthcare in circumstances where healthcare workers may otherwise (perhaps legitimately) opt out. Fourth, payments for risk would guarantee an efficient healthcare system in pandemic situations. Finally, we address two likely objections that some might raise against our proposal, particularly with regard to incentives, namely that such payments or incentives can themselves be coercive and that they represent a form of undue inducement.

ENT trainees' experience of redeployment during the coronavirus disease 2019 pandemic: a qualitative study

Background

As a response to the acute strain placed on the National Health Service during the first wave of coronavirus disease 2019 in the UK, a number of junior doctors including ENT trainees were redeployed to other clinical specialties. This presented these trainees with novel challenges and opportunities.

Methods

A qualitative study was performed to explore these experiences, undertaking semi-structured interviews with ENT trainees between 17th and 30th July. Participants were recruited through purposeful sampling. Interview transcripts underwent thematic analysis using Dedoose software.

Results

Seven ENT trainees were interviewed, ranging from specialty trainee years four to eight (‘ST4’ to ‘ST8’) in grade. Six core themes were identified: organisation of redeployment, utilisation of skill set, emotional impact of redeployment, redeployed team dynamics, concerns about safety and impact on training.

Conclusion

The ENT trainees’ experiences of redeployment described highlight some important lessons and considerations for future redeployments.

Short-term impact of the COVID-19 pandemic on patients with a chronic pain disorder

The current Covid-19 pandemic has already had a definite impact on the daily life of many people worldwide. It has been proposed that people with preexisting medical conditions will be harder hit by the pandemic and the subsequent measures to contain the spread of the disease. In this questionnaire-based, observational study, we aimed to assess the impact of the pandemic on patients with a chronic pain disorder, who are treated at a tertiary multidisciplinary pain center.Participants rated the impact of the pandemic on their chronic pain disorder using a self-designed questionnaire. Also, participants filled out the regular follow-up questionnaire to assess a chronic pain disorder measuring among other parameters pain intensity, symptoms of depression, anxiety, stress, and pain-related quality of life.Of 136 eligible patients who presented to our pain center between May 5th and July 17th, 112 agreed to participate in the study (82.4%). Eighty two participants (73.2%) reported a deterioration of the pain disorder using the self-designed questionnaire. The more robust parameters of the regular follow-up questionnaire showed no relevant changes compared to data collected before the pandemic. We were not able to detect any demographic and medical parameters that were clinically relevantly associated with a higher impact of the pandemic.We conclude that a chronic pain disorder is a relatively stable disease that does not change significantly due to external factors, like the Covid-19 pandemic, even if the subjective impact is perceived to be high.

Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system

Background

Reports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes.

Methods

For this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted.

Results

A total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207).

Discussion

Early phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation.

Level of evidence

Level II (therapeutic/care management).

Priority-setting dilemmas, moral distress and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway

Background:

The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction.

Aim:

Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway.

Research design:

A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020.

Ethical considerations:

Ethical approval granted by the Regional Research Ethics Committee in Western Norway (131421).

Findings:

Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful.

Discussion:

By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority.

Conclusion:

Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms.

Impact of COVID-19 Pandemic on the outcomes in patients with Critical Limb Threatening Ischaemia and Diabetic Foot Infection

OBJECTIVE

Examine the impact of Coronavirus-2019(COVID-19) pandemic on the outcomes in patients with critical limb threatening ischemia(CLTI) or diabetic foot infection(DFI).

BACKGROUND

Patients with CLTI and/or DFI are at risk of amputations if not treated in a timely manner.

METHODS

We compared the outcomes in patients with CLTI or DFI during two periods; Period 1[P1] (15/03/2019-31/05/2019) and period 2[P2] (15/03/2020-31/05/2020- corresponding to COVID-19 pandemic).

RESULTS

139 patients were treated in P1 [mean age 70 years (±11), Male:Female=102:37] while 95 patients were treated in P2 [mean age 67(±12), Male:Female=64:31]. The two cohorts were matched regarding Rutherford category (P=0.25) and GLASS classification (P=0.38). Notably, the time from onset of symptom to clinical presentation was significantly longer [31(1-105) days vs 27(0-78) days, (P=0.017)], whereas the time from presentation to first intervention was significantly shorter [3 (0-61) days vs 5 (0-65) days, (P=0.013)] in P2 compared to P1. There was a significantly higher WCC(P=0.014) and CRP(P=0.004) on admission in P2. Having treatment for CLTI or DFI in P2 was an independent predictor of worse primary patency rate and Freedom from major adverse limb events (F-MALE). At 90 days, amputation-free survival (AFS) and Limb salvage (LS) were noticeably worse in P2 compared to P1 (AFS was 80% and 87% while LS was 64% and 72% in P2 and P1 respectively).

CONCLUSIONS

Patients with CLTI and DFI experienced a significantly delayed presentation with features of sepsis on admission in P2. Treatment in P2 was a predictor of worse primary patency and F-MALE and therefore close and long follow-up is advisable.

Sexual attitudes of healthcare professionals during the COVID-19 outbreak

During the COVID-19 outbreak, which is effective worldwide, the psychological conditions of healthcare professionals deteriorate. The aim of this study was to examine health professionals’ changes in their sexual lives due to the COVID-19 outbreak in Istanbul, Turkey. This online survey was conducted between 2 and 26 May 2020 with 232 healthcare professionals working in a pandemic hospital. After obtaining informed consent, a questionnaire was sent online from the hospital database and health institutions social media accounts (Twitter®, Facebook®, Instagram®, WhatsApp® etc.) and e-mail addresses. The first section of the four-part questionnaire included demographic data, the second and third sections of pre-and post-COVID-19 attitudes, and the last section to assess sexual functions (International Index of Erecile Function for male and Female Sexual Function Index for female), anxiety and depression. Dependent sample t-test, Mc Nemar test, and multivariate analysis were used.The study was completed with 185 participants in total. Healthcare workers’ sexual desire (3.49 ± 1.12 vs. 3.22 ± 1.17; p = 0.003), weekly sexual intercourse/masturbation number (2.53 ± 1.12 vs. 1.32 ± 1.27; p < 0.001), foreplay time (16.38 ± 12.35 vs. 12.02 ± 12.14; p < 0.001), sexual intercourse time (24.65 ± 19.58 vs. 19.38 ± 18.85; p < 0.001) decreased compared to the Pre-COVID-19 outbreak. In addition, participants prefer less foreplay (p < 0.001), less oral sex (p < 0.001) and anal sex (p = 0.007) during COVID-19 and more non-face to face sexual intercourse positions (p < 0.001). When factors affecting sexual dysfunction were analyzed as univariate and multivariate, sexual dysfunction was shown to be significantly more common in males (OR = 0.053) and alcohol users (OR = 2.925). During the COVID-19 outbreak, healthcare workers’ sexual desires decreased, the number of sexual intercourses decreased, their foreplay times decreased, and their sexual intercourse positions changed to less face to face.

Beyond Duty: Medical "Heroes" and the COVID-19 Pandemic

When infectious disease outbreaks strike, health facilities acquire labels such as "war zones" and "battlefields" and healthcare professionals become "heroes" on the "front line." But unlike soldiers, healthcare professionals often take on these dangerous roles without any prior intention or explicit expectation that their work will place them in grave personal danger. This inevitably raises questions about their role-related obligations and whether they should be free to choose not to endanger themselves. In this article, I argue that it is helpful to view this situation not only through the lens of "professional duty" but also through the lens of "role-related conflicts." Doing so has the advantage of avoiding exceptionalism and allowing us to draw lessons not only from previous epidemics but also from a wide range of far more common role-related dilemmas in healthcare.

Ethics of kidney care in the era of COVID-19

The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.

Balancing health worker well-being and duty to care: an ethical approach to staff safety in COVID-19 and beyond

The COVID-19 pandemic has highlighted the risks that can be involved in healthcare work. In this paper, we explore the issue of staff safety in clinical work using the example of personal protective equipment (PPE) in the COVID-19 crisis. We articulate some of the specific ethical challenges around PPE currently being faced by front-line clinicians, and develop an approach to staff safety that involves balancing duty to care and personal well-being. We describe each of these values, and present a decision-making framework that integrates the two. The aim of the framework is to guide the process of balancing these two values when staff safety is at stake, by facilitating ethical reflection and/or decision-making that is systematic, specific and transparent. It provides a structure for individual reflection, collaborative staff discussion, and decision-making by those responsible for teams, departments and other groups of healthcare staff. Overall the framework guides the decision maker to characterise the degree of risk to staff, articulate feasible options for staff protection in that specific setting and identify the option that ensures any decrease in patient care is proportionate to the increase in staff well-being. It applies specifically to issues of PPE in COVID-19, and also has potential to assist decision makers in other situations involving protection of healthcare staff.

Disease Prevention Knowledge, Anxiety, and Professional Identity during COVID-19 Pandemic in Nursing Students in Zhengzhou, China

PURPOSE

This study aimed to evaluate nursing students' understanding of the prevention of COVID-19, as well as their anxiety towards the disease and their perception of their professional identity in the wake of the pandemic, in Zhengzhou, China.

METHODS

A cross-sectional study was designed to investigate 474 nursing students by cluster sampling using a stratified questionnaire from February 15 to March 31, 2020. Multiple linear regression was used to identify the factors affecting professional identity. Binary and multiple logistic regression were used to identify the factors affecting anxiety.

RESULTS

Responders with a high level of understanding of COVID-19 and frequent use of behavioral strategies for its prevention comprised 93.2% and 30.0% of the cohort, respectively. Professional identity was significantly associated with gender and anxiety (p < .050). The prevalence of anxiety among nursing students was 12.4%. Male (odds ratio [OR] = 2.39; 95% confidence interval [CI] = 1.26~4.52), sophomores (OR = 5.30; 95% CI = 1.61~7.45), and infrequent use of prevention measures (OR = 3.49; 95% CI = 1.16~5.19) had a significant effect on anxiety.

CONCLUSION

Anxiety during the COVID-19 epidemic gives an adverse effect on the professional identity of nursing in students. Nursing education institutions need to provide psychological counseling services for nursing students, in addition to improving their teaching of COVID-19 prevention strategies.