REVIEW OF RELATED LITERATURE

This chapter presents the related literature and studies about the delivery of nursing care

services and the shortage of nurses and topics discussed in this research to explain the theoretical

context of the study.

REVIEW OF RELATED LITERATURE

This chapter presents the related literature and studies about the delivery of nursing care

services and the shortage of nurses and topics discussed in this research to explain the theoretical

context of the study.

Delivery of nursing services in the Philippines

  According to Chavez & Santos (2016), nurses are responsible for all aspects of caring for

and comforting clients and their family members in the bedroom. In general, concern depends on

the ability of nurses to recognize clients, who are unique individuals with different values and

choices. Customer satisfaction is the only indicator of the health services provided by the

hospital and the volume of the LPU-Laguna Journal of Allied Medicine. 3 No. 1 August 2018 34

Research, Publication, and Intellectual Property Center LPU-Laguna Their staff are helpful. For

nursing care to be perceived by clients, healthcare providers, especially nurses, must adapt to the

needs and expectations of their clients. In our modern age, hospitals and companies are utilizing

the best effect of technology on healthcare providers to provide efficient and fast health care to

customers.
 Any areas of nursing are overwhelmed by other workloads, such as paperwork and other

legal documentation, it has become a challenge for nurses to fulfill the specifications of the high-

technology procedures of each hospital. Some nurses tend to have difficulties engaging in the

human aspects of treatment in preserving the quality of hospital protocols using technology as

discussed by a study formulated by Benitez (2018).

According to Feliciano (2019), it is difficult to evaluate the competency of nurses when

no particular approach is devoid of its examination. It thus contributed to the identification of

influencing features on the skill of nurses in the delivery of healthcare services. Therefore, they

concluded that the level of competency of nurses in allocating healthcare services in the

Philippines is mostly dependent on demographic (marital) and career-related features (nature of

work, compensation, the period of service). 

The Nursing Registry was developed in 2004 by committed and professional nurses who

deeply understand the meaning of patient care quality, compassion, and trust. We remain

dedicated to delivering nursing services of the highest quality and efficiency to the clients. We

are certified and comply with nationally and globally recognized requirements by the country's

premier hospitals. Our Healthcare Associates offer qualified nursing services and are paired with

our clients to give them the best possible treatment, whether in their own homes, an assisted

living facility, or any healthcare institution. Active Duty Nurses, Nurse Auxiliaries, and

Caregivers. In Manila, Philippines, they are the largest full-service nursing registry; we deliver

highly trained healthcare associates who can be ready even at a moment's notice. Best of all, we

are available 24 hours a day to serve your needs.

According to Worldometers (2020), the rapid growth of coronaviruses, just about

11,662,574 cases worldwide with 539,764 total number of deaths, is affecting different sectors

not only in the financial market but also to the health of the population.  Nurses play a vital role

that requires adequate protection such as crises, providing direct patient care which may consist

of increased patient exposure, and reducing the risk of exposure to the infectious disease. 

In the journal of Nursing Studies Advances (2020), they interviewed some registered

nurses that stated that the clinical background was viewed by registered nurses as highly

complex, yet rapidly adapted to the delivery of pandemic-related treatment. While being afraid

of contracting or transmitting infection, they felt a "sense of responsibility" to care for patients

with COVID-19. Registered nurses have reported greater patient exposure relative to clinical

colleagues and have undertaken duties previously delegated to other members of the clinical

team.

During the pandemic, the experience of caring for patients led to some emotions,

including anxiety, proudness, and interaction with team members. Taken together, the results

demonstrate major consequences for the support of systems and procedures relevant to the

delivery of nursing care during emergencies.

According to Falcura (2020), recent literature has established the adverse effects of stress

on the psychological well-being and work outcomes of nurses. Depression usually develops from

situations in which a person has no control over any infection. Currently, there is an increasing

number of studies on how the COVID-19 epidemic has caused increased stress in various health

systems around the world. This has compromised staff, especially nurses. In fact, among health
workers, nurses are found to be the most interested and stressed in caring for and treating

patients infected with the COVID-19 virus.

While there is a relatively manageable number of COVID-19 cases in the Philippines in

comparison to other leading nations, the country's health care system is still not prepared for this

form of vital health and safety crisis (Torrentira,2020).

Philippine healthcare delivery system

The Philippines is a culturally diverse island nation with more than 7,641 islands in the

Southeast Asia region. Speaking 104.9 million people in more than 170 languages, the country is

considered to have the twelfth population in the world. It is one of the fastest growing economies

in Asia with a GDP growth rate of 6.2% in 2018 (World Bank 2019). It has an urbanization rate

of 51.2%, with a poverty rate of 6.1% as of 2015 (Philippine Statistics Commission (PSA) 2018,

World Bank 2020). Its economy relies on three broad sectors: services, agriculture, and industry

(World Bank 2018). Although the Philippines has shown significant improvements in health

outcomes, it continues to face inequalities and new challenges that threaten the health of its

population. Filipinos also continue to experience a large financial burden due to health care

costs.

 Life expectancy at birth increased from 62.2 years in 1980 to 69.1 years in 2016. It was

brought about by the improvement of living conditions, better access to health services, and

improved management and treatment of infectious diseases in recent years (World Bank 2019).

However, those with lower wealth, less education, or living in rural areas are still at a

disadvantage. For example, family planning and MNCH indicators show that these population

groups have higher infant mortality and fertility rates compared to the national average, and
lower percentages of deliveries occurring in health facilities and assisted by efficient health care

providers. The health system now faces three burdens: the health impacts caused by

urbanization, globalization and climate change, the rise of non-communicable diseases, and the

re-emergence of infectious diseases (Daredevil, Lagarda and Picasso et al. 2018).

Health care facilities are level I, level II, and level III in the Philippine health system.

Level I (Primary Level of Health Care Facility) are rural health units, their sub-centers, chest

clinics, malaria eradication units, and schistosomiasis control units are directly run by the DOH;

puericulture centers operated by the League of Puericulture Centers; tuberculosis clinics and

schistosomiasis control units. The smaller, non-departmentalized hospitals, including emergency

and regional hospitals, are Class II (Secondary Level of Health Care Facilities). Services offered

to patients at symptomatic phase of the illness require relatively specialized information and

skills resources to provide proper care. The highly technological and specialized services

provided by medical centers and major hospitals are Class III (Tertiary Level of Health Care

Facilities). There are the National Specialist Hospitals. The programs offered at this stage are for

patients suffering from diseases that are severely threatening their health and need extremely

technical and specialist expertise, equipment and staff for successful care (All Answers Ltd.

2018).

Nurses Role in the healthcare delivery system

According to Susan (2017), As we shift from episodic, provider-based, service-based

maintenance to group-based, patient-centered, nurses are positioned to contribute and guide the

transformational changes that occur in health by being a full-fledged member of the professional

team. Continuous care that provides seamless, affordable, and quality care. These changes

require new or improved knowledge, skills, and approaches surrounding health and population
care with a renewed focus on patient-centered care, care integration, data analysis, and quality

improvement.

According to WHO (2018), Nurses have different roles within their job description. The

roles of a nurse include manage and treat patients and work with relevant families and

communities on health and hygiene development. Also, nurses are expected to contribute to

improving public health and improving the health of individuals in the community.

According to the Swedish Society of Nursing, (2016), a nurse is expected to demonstrate

professional values such as respectful response, kindness, trustworthiness, and honesty in her

work. Nurses have to update themselves on evidence-based care and to gather new knowledge

for continued competence. Nurses in co-workers and other fields are expected to maintain a

cooperative and respectful relationship. Nurses are expected to take appropriate action to protect

individuals, families, and communities when health is compromised by a co-worker or any other

individual. Also, nurses are expected to promote and support co-workers in ethical behavior.

Effects of the pandemic on nursing care

The rapid and undetectable spread of COVID-19 and the (possibly) higher (compared)

death rate compared to COVID-19-related pneumonia combined to create the current epidemic,

which has far-reaching health, economic, and social well-being worldwide. The vast majority of

resources and resources have been invested in the prevention and treatment of severe pneumonia,

increasing the burden, and threatening the end of global health systems. Restrictions on normal

life, trade activities, travel and the closure of cities and countries to prevent the spread of

COVID-19 have had a significant impact on the global economy, threatening economic stress

(Anzai et al., 2020).

one ICU nurse is assigned to each patient initially. Then when the number of patients increased,

a switch to the 2: 1 ratio was made again. As of March 2020, many countries or regions where

COVID-19 has hit the hardest are likely to travel at a rate of more than 2: 1. However, there is

good news of success on how nurses have been helping each other, so all patients have been

getting the care they need. (Keshavan M. 2020)

According to Andrea, (2020), the decline in child immunization rates has been evidenced

worldwide during previous epidemics, due to over-health counseling programs, parents not

bringing their children to meetings, and burglaries the sale of goods due to broad restrictions.

The effect of a missed vaccination can be devastating; on time the last outbreak of Ebola in the

Democratic Republic of the Congo, twice the number of children killed by measles than those

killed by Ebola. A decline in vaccination rates during the COVID-19 epidemic could lead to the

subsequent outbreak of infectious diseases when removing the limits of social exclusion.

Increasing the capacity of the hospital bed and taking care of the protective equipment, more

hospitals as well surgery centers have postponed elective surgery, many on request and under the

administration of government orders. Doing so, however, can increase the complexity of the

process, the risk of infection, the progression of the disease, and the duration of recovery. Also,

standard post-processing resources may have limited availability.

Normal Nursing Shift Hours

Standard nursing shifts may be eight, ten, twelve, or sixteen hours in duration and May

does not follow the standard pattern of the day, night, and night shifts. Usually, a 12-hour shift

begins at 7 p.m. and finishes at 7 a.m., some begin at 3 a.m. and finish at 3 p.m. Nurses working
in specialized units such as surgery, dialysis, and intensive care are often expected to work extra

hours (on-call) in addition to their daily scheduled shifts. 

Furthermore, depending on where a registered nurse works, they may be required to work

at particularly scheduled times of the day, such as morning, noon, or night shift rotations. In

facilities such as hospitals, 24-hour clinics, emergency care centers, assisted living facilities, and

emergency care facilities where patients require care at all times of the day, registered nurses are

always on staff to take care of any patient suffering from illness, medical condition or injury.

In Capitol Medical, nurses work for a total of 40 hours a week. Two days with twelve

hours of duty, two days with eight hours of duty, then three days off per week, Caday said. They

did not adjust the number of hours of duty each week. At the end of last month, 12-hour nurse

shifts at Medical City in Pasig were rolled back to 8-hour shifts because they did not want their

nurses to get exhausted and over-fatigued Back-up nurses were called in from the other

departments of the hospital to carry the load. Related to this, the Philippines has different shifting

hours depending on the hospital they are in. 

Normal Nurse to Patient Ratio

The American Nurses Association (ANA) promotes a policy model in which nurses are

encouraged to establish staffing strategies specific to each unit. This method allows hospitals to

create staff levels that are versatile and represent changes, including the intensity of patient

needs, the number of admissions, discharges, and transfers during shifts, the level of experience

of nursing staff, the configuration of the unit, and the availability of resources, such as clinical

staff and technology.

California is the only country that has legally established the minimum nurse-to-patient

ratios required to be maintained at all times by unit. For example, the nurse-to-patient ratio in the
critical care unit must be 1:2 or less at all times, and the nurse-to-patient ratio in the emergency

room must be 1:4 or less at all times while patients are seeking treatment, according to the law.

Growing the nurse-to-patient ratio is one of the most important issues to be explored in

the world of nursing. In general, nurses across various countries are asked to take care of more

patients at a time, and individual states or health centers are left to cope with the growing

problem. A balanced nurse-to-patient ratio can lead to a variety of positive outcomes. Higher

levels of work satisfaction are seen when nurses have fewer patients to take care of at one time.

Also, the quality of patient care decreases as the number of patients in a nurse’s care increases. 

According to Mendoza, the shortage of human resources has a direct effect on the

delivery of quality health care to patients. According to the Philippines Department of Health,

the ideal nurse-to-patient ratio is 1:12, but this is hardly true in many hospitals. If something

happens and if one patient is at a critical point, the nurse must pay close attention to the

particular patient so that the patient does not die. However, since others have fewer nurses on

staff, they cannot pay close attention to the patient, since they also have to take care of the other

patients. 

Number of Hours per Station

As previously promoted by Florence Nightingale, nurses have always played an

important role in infection control, control, isolation and prevention, and the health of the

community. Today, they have become one of the leading patient care providers for coronavirus

2019 (COVID - 19) disease in the fight against infection, which brings new challenges for

nurses, (Smith, NG, & Ho, 2020)

Due to the shortage of nurses, nurses not only work long hours in isolated wards but also

wear protective clothing for 80- to 12-hour shifts, which causes weakness and awkwardness. For
example, wearing long N95 masks creates bloody marks on the faces of nurses. Long working

hours are associated with patient errors and side effects (Uncord, Groger-Jarvis, and Davis,

2019).

With the rapid increase in the number of patients, which may result in severe nurse

shortages, it is important to ascertain a scientific, reasonable nursing shift schedule. We tried 3

shift schedules: (1) 4-hour add in the morning and 4-hour add in the afternoon with 8-hour

breaks; 6 hours of continuous work; And (3) 6 hours of continuous work, 1-hour overlap at the

tip of the following nursing shift. After a 1-week trial of various shifts, a questionnaire survey

was conducted among 78 nurses to work out their preferred shift schedule and their causes.

Results showed that 74% of nurses preferred the 3rd schedule for the subsequent reasons:

increased consumption of medical resources by injecting and taking PPE twice a day; Frequent

movement between contaminated and clean areas may increase infection; the fastest-growing

frequent practice of complex procedures like placing and taking PPE increased their mental

burden; not having the ability to travel to the toilet while wearing the PPE within the isolated

area, working for six hours constantly pushed their physiological limits, and that they often felt

tired or exhausted at the tip of the work; And (5) having 1 hour of overtime between shifts

provided flexibility and facilitated delivery, which reduced nurses' stress and therefore the

possibility of adverse events.  

Additionally, 1-H overlap allows two nurses to collaborate to complete tasks that are

difficult for one person to finish, like injecting and drawing blood for kids, changing sheets, and

disinfecting the terminal room, (Lishan et al, 2020).

According to American Journal of Infection Control, (2020), because of the sudden

outbreak of the disease, nurses from the Department of Infectious Diseases had to enter the

negative stress ward to care for patients only after brief training on COVID-19. Before beginning

nursing duties for COVID-19 patients, nurses from other departments had to go through 3

training stages: pre-training, adaptive training that provides nursing to other patients in the

infectious field, and negative stress ward training. This process took about 1 week. Nurses who

enter a negative stress ward will work for 0.5-3 months before being transferred to other anti-

infective conditions. As COVID-19 is a new disease and the medical system and culture of

different countries vary, more research is needed on the psychological experience of leading

nurses fighting COVID-19. Currently, published studies highlight the prevalence of the disease, 

clinical features, diagnosis and treatment. Some reports focus on the severity of psychological

problems in medical personnel and the urgency of providing psychological care.

This review consolidates evidence of health effects of COVID-19 in HCWs. Our findings

suggest that HCWs may be exposed to a variety of health effects from COVID-19 infection. For

those with COVID-19 infections, the most common symptoms were fever and cough, which

were similar to those found in the community. Several risk factors were identified; Long duty

hours, working in a high-risk field, absence of BPE, detected family members, inappropriate

hand washing and improper infection control. Furthermore, long-term PPE use led to skin

damage, with the nasal bridge being the most common site. Fighting COVID-19 at the forefront

is causing HCWs to become depressed. Findings show high levels of depression, stress, anxiety,
depression, anger, fear, insomnia and post-traumatic stress disorder in HCWs. Women and

nurses are more likely to suffer from mental illness. Leading female nurses work long hours in

close contact with patients, which can lead to fatigue, depression and anxiety. However, this

discovery guarantees further research into the best products for the future. (Shaukat et al., 2020)

The global COVID-19 epidemic has created a massive public health crisis and a number

of challenges for health workers. The infection, caused by the SARS - CoV - 2 virus, was the

worst infection since the Spanish flu a century ago, with its rapid person-to-person transmission

to many health systems (Marinis, 2020; Samakis et al., 2020). Leading health workers are

experiencing greater exposure to the virus. In Italy, about 10,000 health workers will be affected

by the beginning of April 2020, for which many essential workers will have to be isolated or

isolated (Cherchis et al., 2020). Increased work intensity, lack of effective treatment or

vaccination, and fear of being infected and affecting loved ones have had significant negative

impacts on the mental health of health care workers due to the care of COVID-19 patients

(Kisley et al., 2020). It is important to understand the various factors that affect the psychological

well-being of leading health care workers during these unusual epidemics, which may help to

design specific interventions to minimize negative persistence (Orton & Silcott, 2020)

Spiritual Health

According to Nicolette et al., (2020), Spirituality has been a foundation for all population

groups since the beginning of recorded history. It is an integral part of the quality of life, health

and well-being of the general population and affected by disease. Relationships with

transgressors or saints have a strong influence on people's beliefs, attitudes, emotions and

behavior. Research shows that families rely on their spirituality for emotional, mental and
physical well-being. Spiritual practices are recognized as life-changing and powerful coping

tools for dealing with traumatic events.The effects of COVID-19 have a profound impact on the

activities, practices, livelihoods, mental health and well-being of people and leading health care

workers. Encouraging compassionate care. People with COVID-19 present with severe trauma

associated with the disease that affects various aspects of their wholeness, including physical,

emotional, mental, social and spiritual components. 6 This means that health workers need to

create a supportive environment that can encourage interdependence through a transformative

approach to spiritual care. 7 This means that all patients and their families should be treated with

dignity and given a voice to express their concerns regardless of gender, religion, culture, race,

sexual orientation and disability 

According to Thuli et al.,  (2020), Spiritual care includes the activities that health workers

are involved in improving the quality of life and well-being of their clients. The activities of

health workers and people involved in COVID-19 include compassionate presence, listening to

patients 'fears, beliefs and dreams, obtaining spiritual histories, and being attentive in all areas of

patients' lives and their families. However, with regard to COVID-19, some activities, such as

chaplain involvement and spiritual practices, may be limited due to precautionary measures to

control the infection. Spirituality is important in health because it promotes stress-coping

strategies, promotes recovery and regression, and prevents burns.

According to Journal of Public Health, ( 2020), Beliefs and practices are commonly used

in medicine to deal with illness and other stressful lifestyle changes. The benefits of [spiritual

beliefs] to mental health and well-being include physiological effects that can affect physical

health, affect the risk of disease, and affect the response to treatment. '2 Therefore, spiritual care

becomes an integral part of the human psyche An important component of human care, health
and well-being for families, patients and health workers. Moreover, the spiritual care

demonstrated by compassion and empathy soothes a person and provides much-needed relief in

times of high stress, suffering and anxiety. Therefore, sacred or divine faith and the resulting

spiritual experience leads to positive psychological states of peace, healing, contentment, hope

and happiness.

Theory of Interpersonal Relations

The Interpersonal Relations Theory of Hildegard Peplau highlighted the nurse -client

relationship as the foundation of nursing practice. It stressed the giving-and-taking of nurse-

client partnerships that were considered as groundbreaking by many. Peplau continued to

establish an organizational paradigm that stressed the need for a nurse-client relationship as

opposed to the client getting passive care and the nurse behaving passively under the orders of

the doctor. The four components of the theory are: person, that is a developing organism that

seeks to minimize needs-induced anxiety; environment, which consists of current powers beyond

the individual and put in the sense of identity; health, which is a word mark that indicates

personality and nursing forward movement, which is an essential interpersonal therapeutic

mechanism that operates cooperatively. It also includes seven nursing roles: Stranger role,

Resource role, Teaching role, Counseling role, Surrogate role, Active leadership and Technical

expert role (Gonzalo, A. 2019).

Nursing is described in Peplau's theory as an interpersonal, therapeutic mechanism that

happens when clinicians, specially qualified to be nurses, participate in therapeutic relationships

with people in need of health services. In order to be efficient, Peplau theorized that nurse-

patient partnerships would move through three phases: (a) orientation, (b) working, and (c)
termination. Hospitalized patients notice they need assistance during the brief orientation phase

and try to adapt to their current (and often new) experiences. At the same time, as people with

distinct needs and priorities, nurses meet patients and gain vital information about them. The first

role during the orientation phase is that of strangers, amongst many roles that nurses take in their

communication with patients (Hagerty, T., et al. 2017). 

Nurses are originally expected to welcome patients with the "respect and positive interest

granted to a stranger." Patients and nurses rapidly move through this process and nurses must

continue to show kindness and reverence during the three stages. The next step is the working

phase, which corresponds for the most of the time spent with patients among nurses. In this

phase, nurses determine patients to be used for while teaching and when adding to the

interdisciplinary care plan. The functions of nurses become more common to patients during the

working phase; they tend to recognize nurses as health educators, resource individuals,

counselors, and providers of treatment. The final phase is the phase of termination, which is

more generally recognized as discharge planning. The effectiveness of the termination phase is

reliant on how well patients and nurses operated the orientation and working phases. A

significant part of the termination phase happens when nurses educate patients about symptom

management and recovery at home (Hagerty, T., et al. 2017). 

Peplau emphasised that many nursing issues can all overcome strong interpersonal

relations. In the Theory of Interpersonal Relations she developed, she identified four different

stages in the patient-nurse relationship, that is, orientation, identification, exploitation, and

resolution. Orientation is the stage in which the patient needs treatment, and the nurse recognizes

the issue and encourages the patient to understand their problem. At this point, it is especially

necessary to develop a relationship of trust between the nurse and the patient, as this tends to
relieve the patient's anxiety. The Identification stage covers the preparation and goal

determination processes. The nurse offers the patient the ability to open up their feelings and

channel their feelings in a constructive way with the initiation of a healthy friendship - this is

vital for fulfilling the patient's needs. At the stage of Exploitation, presuming that a positive

relation between the patient and the nurse was already created, the patient wants to be reassured

to such an extent that they can now deal with their situation. In addition, professional

collaboration occurs at this point, and the patient-nurse relationship develops. When the patient

accepts responsibility and is involved in conversation, the 'Therapeutic partnership' progresses.

The Last stage, Resolution is where the patient is required to be active in all of the addressed

tasks at this stage. It is vital here to guarantee that no reliance on the nurse is established by the

patient. The patient-nurse partnership ends at this point, when the patient now has the capability

to make independent choices (Arabaci, L., & Tas, G. 2019).

Quality and safe nursing care

Patient care is a health issue of global concern, and nurses must be competent in their

ability to provide care services based on relevant nursing standards. Nursing skills are the key

skills needed to perform one's role as a nurse (Fukata, 2018), and the P.S.C. Besides, proper tests

can be done to P.S.C, as diagnostic tools for identifying strengths and weaknesses, to guide for

the competency improvements of the benchmarking.

According to Juliana, (2015), in a global context, where science, technology, and

knowledge are available to more people, technology, and especially nursing, are faced with the
need to improve their work processes to ensure the highest quality care for patients. Nurses are

aware of the quality work of their patient care provider, institution, ethics, rules, and standards of

professionalism, and how their effectiveness affects the balance of patient care and satisfaction.

Thus, listening to what patients have to say about the care they receive and their satisfaction can

be an opportunity to create an indication of the results, giving managers some lessons to decide

on change and innovation.  

According to Centers of Medicare and Medicaid Services, (2020), as part of President

Trump’s efforts to reopen the United States, an independent commission of the Center for

Medical and Medical Services (CMS) will conduct a comprehensive assessment of the nursing

home’s response to the 2019 novel Coronavirus (Covit-19) epidemic. The Commission will be

convened and guided by a CMS Contractor and will make independent recommendations to the

Contractor to review and report on the CMS to enable immediate and future responses to

COVID-19 in nursing homes. These facilities are responsible for the increasingly vulnerable

population of Americans who are often at high risk for complications from the COVID-19 virus.

The initiative creates the five-part plan to ensure the safety and quality of CMS administrator

Seema Verma's nursing homes in the United States, announced in April 2019, and the latest

agency efforts to combat the spread of COVID-19 within these facilities. Safety errors are based

on total working hours per day and the experience of nurses in the field (Kendall-Gallagher &

Blegen, 2018). There are six basic skills that nurses are expected to follow but the focus of this

study is on a high level of patient safety.

Demonstration of appropriate knowledge and skills

information sharing, and the implementation of public health policy is widely trusted and

anticipated. Therefore, clinical nurses should have time to review and learn about specific risks

associated with their work environment (e.g., hospital wards, ICUs, pediatric hospitals, maternal

and child health, nursing homes, schools, etc.). This education should also be extended to

nursing students, who may be introduced during the epidemic to support their colleagues. (Choi

et al., 2020)

To ensure effective nursing education during the epidemic, health facilities that employ

nurses must ensure the availability of resources (ANA, 2020), (Choi K. et al., 2020)

According to Yonago Acta Med, (2018), health care has changed drastically due to issues

such as rapid morbidity and morbidity and mortality rates. Accordingly, health and care provider

systems are changing. For example, when a patient has a serious medical problem, the hospital is

expected to provide short-term, intensive care. Home care is needed to provide support to treat

the patient / her with dignity and respect for the rest of her / her life after treatment. Therefore,

nurses should provide comprehensive care that meets the complex and diverse needs of patients.

This is required for all nurses, regardless of work setting; Currently, there is a growing

expectation that nurses will be able to combine different sources of information into their

decision-making and nursing training.    

Patient care is a health issue of global concern, and nurses must be competent in their

ability to provide care services based on relevant nursing standards. Nursing skills include the

key skills needed to play a role as a nurse (Fukada, 2018)

According to Alyssa (2020), Another role that nurses play during the epidemic is the

maintenance of medical equipment and protective equipment such as masks, gloves, and hand
sanitizers. These resources can easily be depleted during a disaster, and nurses play a key role in

protecting these services from theft or accumulation. While researchers fight viruses such as

SARS-CoV-2 in laboratories and medical studies, nurses face this direct threat, direct contact

with countless patients who may be infected. Their role is critical to the overall functioning of

health care and response to epidemics - to diagnose, evaluate, and evaluate patients quickly and

effectively. Nurses are ready for this task because of their experience already working directly

with patients. By touching that information and quickly diagnosing the patient's condition, the

spread of the disease can be greatly limited. Patients who check for symptoms or signs of the

disease are soon referred to themselves, protecting other patients who may not have the disease,

and primarily for the hospital's nursing staff to carry out infectious diseases - additional measures

and community outreach strategies designed to prevent Coronavirus from spreading rapidly

within the hospital.

According to Levett‐Jones et al., (2020), to evaluate the PSC (Patient Safety

Competency) for nurses, as diagnostic tools to identify strengths and weaknesses, to guide skills

development, and to do benchmarking. However, a widespread challenge in the development of

tools specifically for testing PSC nurses is uncertainty about the safety features of active patients.

The PSCF includes skills and knowledge statements divided into nine domains (nine basic

skills): medical communication, personalized care, collaborative and collaborative work,

prevention, mitigation and response to adverse events, cultural power, infection control and

control, drug safety, evidence-based practice, and clinical thinking. The framework is based on

Miller's pyramid of skill. In the PSCF (Patient Safety Competency Framework), for the first

time, knowledge is considered the basis of competence. Next, nurses need to know how to apply
knowledge using cognitive skills such as critical thinking. Finally, nurses practice their

knowledge and skills in performing clinics.

Sound decision –making

Clinical decision-making (CDM) in nursing is a complex process associated with nursing.

CDM is an important skill that a nurse uses in clinical practice, results from critical thinking,

which includes clinical knowledge and experience, and is defined as a process of selecting

alternatives to the provision of patient care. Decisions made by nurses affect patient care, safety,

and results. Benner developed an accurate, decision-making model, called "From Novice to

Expert", in which he described the five stages of skills acquisition in the clinical knowledge of

nursing, namely novice, advanced, competent, competent, and professional nurse. These five

sections reflect changes in three common aspects of skills acquisition skills and the CDM: from

relying on vague principles to past concrete experiences, changing the perception of the situation

from clarifying certain parts to seeing a more complete picture and moving from a remote view

to an active nursing skills player (Nikolina, 2020)

Nursing research further explores key components in nurse decision-making that include

experience and intuition, the context of decision-making, patient cognition, interpretation, and

reflection. Finally, making sound clinical decisions requires a shared approach to ensuring that

care is patient-focused, cost-effective, and of the highest quality. Collaboration and

communication between health professionals, therefore, is critical to making appropriate patient

care decisions, (Johansson & O’Brien, 2015).

Following data collection, various factors influence nurses' responses when making

decisions. For example, gradual changes against abrupt changes in the patient's condition led
nurses to respond differently (Bratton, 2015). Nurses should gather additional information,

including patient information indicating gradual change, and discussion with experienced

colleagues before making decisions (Bratton, 2015). A sudden change led nurses to make

quicker decisions (Bratton, 2015). Nurse decision making can respond not only to physiological

indications but also to complex factors such as the progression of the change to the patient's

various stage indications.

Understanding the patient's condition is an important and critical part of the decision

making for nurses. To understand the patient’s condition, the nurse must invest time, gather

physiological notes, determine which tips are important, communicate often with technology,

and determine how to respond to information gathered as part of their decision-making process.

Promotion of clients’ safety

  According to ILO, (2020),  Ongoing monitoring of OSH conditions and appropriate risk

assessments will be required to ensure that control measures related to the risk of infection are

adapted to specific changing processes, working conditions, and employee characteristics during

critical and post-infection events, so that recurrence can be prevented.

Florence Nightingale is one of the first nurses and pioneers to deal with epidemics of

hygiene and cleanliness. Nightingale has highlighted the relationship between infection control

and hand washing (World Economic Forum, 2020)

Florence Nightingale's nursing lessons during the Crimean War are still in use today

during the COVID-19 epidemic - important handwashing, hygiene standards, data readings, and

more. (Bonnie et al., 2020)

(WHO-PED) is developing strategies, efforts, and strategies to deal with emerging and emerging

diseases to reduce the impact on affected populations and reduce global spread. Part of the

policies and procedures focus on the role of the nurse-led health care team in how to deal with

patients with the illness. As this is an HIV / Aids epidemic, all COVID-19 agreements are

expected to be ratified mainly by nurses and community health workers. At the same time,

nursing leaders need to develop more effective solutions (Corless et al., 2018)

Nurses play a key role in providing public education, especially in the prevention of infectious

diseases and in reducing the spread of misinformation (Wen et al., 2020)

The main role of nurses in the global response to the novel coronavirus of a novel like

COVID-19 is to help patients cope with their concerns. However, nurses are expected to play a

vital role in preparing for and managing the epidemic. The role of nurses in the epidemic begins

even before the disease has a chance to cause widespread destruction. Briefly, about the 2018

policy, the ANA said nursing leaders are key to preventing and containing widespread diseases.

They have the skills and education to improve global communication and the identification of

infectious diseases (American Nurses Association 2020).

Setting Priorities

According to Suhonen et al. (2018), Nurses were also personally responsible for the

treatment of multiple patients and the duty of prioritizing their everyday tasks in nursing care.

Besides, studies showed that priorities set by nurses entail prioritization between patient

categories, patients with particular conditions, the complexity of the condition of the patient, age,

and the possible benefits to patients from medication and care. The detrimental results of the
priority setting practice are the moral frustration of most nurses, missing treatment, which affects

both patient outcomes and nursing clinical practice, and the compromise on the standard of care.

Thus, prioritizing the multiple assessed demands for treatment and balancing consequential

contradictory perceptions tests both the ethical and philosophical values of nurses.

Using a variety of methods and frameworks, including the ABCs, Maslow's Hierarchy of

Needs, and the ABCs/MAAUAR system, priorities are created.  Awareness of these structures

and an in-depth understanding of pathophysiology allows people to make better-set goals for

treatments that are then provided to particular clients and groups of clients of differing acuity

criteria and varying priorities (Burke, 2020).

Thus far, limited research in bioethics has concentrated directly on setting priorities for

public health science. Nevertheless, global health research priority-setting elements pose legal

issues and health justice-related concerns (Pratt et al, 2018).

Implementation of Sound Nursing Care

Clinical judgment is an abstract term synonymous with the decision-making concept.

Critical thought and medical judgment result from it. Administrators and educators should use

objective and accurate approaches to recognize the involvement, encourage growth, and evaluate

the existence of clinical judgment in inexperienced nurses with the overall goal of improving

patient care using these results (Manetti, 2018).

In dynamic patient care settings, nurses use clinical judgment, collaborating with inter-

professional partners to ensure the consistency and safety of healthcare services. Essential

elements include patient status adjustments, ambiguity over the most fitting plan of action,

background accounting, and the practical expertise of the nurse. Clinical decision making is

embedded in the analytical experience of the nurse; ethical perspectives; connections with
patients, guardians of the patient, and the community; and awareness of the effect of structures

on results of health care .

Higher cognitive abilities are crucial qualifications for nurses to deliver efficient and

productive nursing services by entering the technologically and increasingly complicated health

care setting. The more skilled a nurse is, the less presumably the patient will be to acknowledge

whether particular procedures have been administered. There is a distinction between health

services rendered by licensed trained nurses and non-professional carers (Graan, A., Williams,

M., et al. 2016).

Ensuring Continuity of Care

In general practice, continuity of care has always been the core principle. Improved

clinical outcomes, greater retention rates, and more cost-effective health services are only some

of the benefits that the patients who receive proper care maintenance experiences (Jeffers, H. &

Baker, M. 2016). 

Maintaining the continuity of care ensures that the nurse and other healthcare members of

staff determine current patient needs and then transfer the patient in a timely and productive

fashion to the proper treatment location, to the appropriate level of care, and the correct

healthcare facility. Communication, coordination, and cooperation are important components of

the quality of service within and between relevant members of the clinical staff and the patient

(Burke, 2020).

Many patients, families, and caregivers receive inconsistent, improperly coordinated care

from various providers without good quality or consistency of care and assistance, often with

disastrous consequences and risk of injury due to communication inadequacies, insufficient

preventable hospitalizations or readmissions. This is a specific challenge for patients with

chronic or complicated conditions needing treatment and assistance, several of whom in both

high-income and low-and middle-income (LMI) countries have several disorders associated with

low-income or severe situations that are most underserved. Therefore, continuity and care

management are national goals for the reorientation of health systems to people's needs. They are

necessary for all healthcare facilities and economies, in a variety of settings and at all stages of

life, for care providers (WHO, 2018).

Participation in Quality Improvement Activities

Healthcare quality management involves a systemic strategy by a healthcare institution

that tracks, reviews, and strengthens quality healthcare standards. To obtain a higher level of

efficiency, the corporate sequence of operations is cyclical and requires continual development.

Continuous development in healthcare practices will pull healthcare institutions out of inefficient

conventional concepts to use technology/tools to work successfully and thereby achieve

improved quality outcomes (iPatientCare, 2016).

According to Jones et al. (2019), participating in improving quality care services allows

healthcare professionals to develop, integrate, and apply essential clinical skills such as

complexity management and human factors education. It is an incentive for clinical trainees to

optimize care; develop expertise in teamwork, presentation, and management skills to assist their

professional development; and establish partnerships with peers in organizations they have

recently entered. It is a chance for more seasoned practitioners to resolve long-standing queries

about how treatment procedures and systems are implemented, and to affirm their leadership in

developing skills. The benefits of investing in quality enhancement for patients, physicians, and
healthcare professionals are considerable, but there are also difficulties inherent in planning,

delivering, and maintaining an intervention for improvement.

In order to accomplish the threefold aim of enhancing the health of the community,

strengthening patient outcomes and experiences, and reducing the per capita cost of treatment,

and improving professional experience, it is important to involve primary care practices in

quality improvement (QI) programs (Taylor, E., et al. 2020). 

Problems encountered by nurses during the pandemic

Nurses play a key role in reassuring the patient at different times of the disease. With the

variability of COVID-19 symptoms, patients diagnosed with anxiety and need consistent support

and reassurance. Without fear, COVID-19 patients may develop strong emotions and depression;

nurses can find that out with their level of grief and anxiety. COVID-19 patients have many

reasons to panic, especially when they are isolated or isolated from their loved ones, without

having to worry about their health. Therefore, the nurse should play a role in reducing patients

and reducing their uncertainty, false information, more details about the risk of the disease

(Mohamed, 2020)

Many nurses had to set up a clean area at the entrance to their homes to change in and out

of the shower, without change and shower and at work. Their biggest challenge was to stay

healthy so that they could continue to care for others. Despite the concerns of infection with

COVID-19 patients, the commitment to a smiling face, humor, and chocolate distribution have

continued to be common among many nurses. The spirit of cooperation and consultation of those

in need was demonstrated in many reported cases. (Keshavan, 2020)

although the conditions and environment in Wuhan were challenging and extreme when there

was a severe shortage of PPE. Many nurses had to refrain from eating and drinking for two hours

before entering the isolation room, to save energy and the time it took to put on and remove

protective clothing. This has escalated as they have become frustrated with emergency patients

and severe staff shortages, as well as a lack of a multi-skilled team to manage respiratory

conditions or doctors.

According to Ayanian (2020),  the situation worsened when a nurse found a colleague

seriously ill and sometimes died of COVID-19 while caring for them. Studies show that long-

term performance, such as that of COVID-19 response nurses, can cause functional impairment.

All health care workers should consider using a series of strategies to reduce their own mistakes

to ensure that they perform well in the workplace. Incorporating personal items to consider the

same state of COVID-19 can help exceed the limit of potential errors caused by nurses and will

improve their resilience at the same time. The RCN (2020) recognizes that the human factor is an

important part of nursing care to prevent avoidable errors and patient injuries. With the closeness

of personal belongings, nurses can provide safe health care and integrated collaborative services.