# MATH 225 Chamberlain University SARS CoV 2 Virus Paper

Required Resources

## Read/review the following resources for this activity:

OpenStax Textbook: Chapter 2

Lesson

• Chamberlain University Library
• Internet
• Scenario/Summary
• This week’s lab highlights the use of graphics, distributions, and tables to summarize and interpret data.
• ## Deliverables

The deliverable is a Word document with your answers to the questions posed below based on the article you find.

## Required Software

Microsoft Word

Steps to Complete Week 3 Lab

• Part 1:
• Step 1: Your instructor will provide you with a scholarly article.  The article will contain at least one graph and/or table. Summarize the article.
• ## Part 2:

### Title your paper: “Review of [Name of Article]”

State the Author:

### Summarize the article in one paragraph:

Post a screen shot of a frequency table and/or graph from the article.

Example:

Frequency Distribution      ORGraph

What typeof study is used in the article (quantitative or qualitative)? Explainhow you came to that conclusion.

What typeof graph or table did you choose for your lab (bar graph, histogram, stem & leaf plot, etc.)? What characteristics make it this type (you should bring in material that you learned in the course)?

Describethe data displayed in your frequency distribution or graph (consider class size, class width, total frequency, list of frequencies, class consistency, explanatory variables, response variables, shapes of distributions, etc.)

Draw a conclusion about the data from the graph or frequency distribution in context of the article.

How else might this data have been displayed? Discuss pros and cons of 2 other presentation options, such as tables or different graphical displays. Why don’t you think those two graphs were not used in this article?

Sugg et al. BMC Nursing
(2021) 20:215
https://doi.org/10.1186/s12912-021-00746-5
RESEARCH
Open Access
Fundamental nursing care in patients with
the SARS-CoV-2 virus: results from the
‘COVID-NURSE’ mixed methods survey into
nurses’ experiences of missed care and
barriers to care
Holly V. R. Sugg1*, Anne-Marie Russell1, Leila M. Morgan1, Heather Iles-Smith2,3, David A. Richards1,4,
Naomi Morley1, Sarah Burnett1, Emma J. Cockcroft1, Jo Thompson Coon1,5, Susanne Cruickshank6, Faye E. Doris1,
Harriet A. Hunt1, Merryn Kent1, Philippa A. Logan7, Anne Marie Rafferty8, Maggie H. Shepherd9,10, Sally J. Singh11,12,
Susannah J. Tooze1 and Rebecca Whear1
Abstract
Background: Patient experience of nursing care is associated with safety, care quality, treatment outcomes, costs
and service use. Effective nursing care includes meeting patients’ fundamental physical, relational and psychosocial
needs, which may be compromised by the challenges of SARS-CoV-2. No evidence-based nursing guidelines exist
for patients with SARS-CoV-2. We report work to develop such a guideline. Our aim was to identify views and
experiences of nursing staff on necessary nursing care for inpatients with SARS-CoV-2 (not invasively ventilated) that
is omitted or delayed (missed care) and any barriers to this care.
Methods: We conducted an online mixed methods survey structured according to the Fundamentals of Care
Framework. We recruited a convenience sample of UK-based nursing staff who had nursed inpatients with SARSCoV-2 not invasively ventilated. We asked respondents to rate how well they were able to meet the needs of SARSCoV-2 patients, compared to non-SARS-CoV-2 patients, in 15 care categories; select from a list of barriers to care;
and describe examples of missed care and barriers to care. We analysed quantitative data descriptively and
qualitative data using Framework Analysis, integrating data in side-by-side comparison tables.
* Correspondence: h.v.r.sugg@exeter.ac.uk
1
College of Medicine and Health, University of Exeter, St Luke’s Campus,
Heavitree Road, Exeter EX1 2LU, UK
Full list of author information is available at the end of the article
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
Sugg et al. BMC Nursing
(2021) 20:215
Page 2 of 17
Results: Of 1062 respondents, the majority rated mobility, talking and listening, non-verbal communication,
communicating with significant others, and emotional wellbeing as worse for patients with SARS-CoV-2. Eight
barriers were ranked within the top five in at least one of the three care areas. These were (in rank order): wearing
Personal Protective Equipment, the severity of patients’ conditions, inability to take items in and out of isolation
rooms without donning and doffing Personal Protective Equipment, lack of time to spend with patients, lack of
presence from specialised services e.g. physiotherapists, lack of knowledge about SARS-CoV-2, insufficient stock, and
reluctance to spend time with patients for fear of catching SARS-CoV-2.
Conclusions: Our respondents identified nursing care areas likely to be missed for patients with SARS-CoV-2, and
barriers to delivering care. We are currently evaluating a guideline of nursing strategies to address these barriers,
which are unlikely to be exclusive to this pandemic or the environments represented by our respondents. Our
results should, therefore, be incorporated into global pandemic planning.
Keywords: Fundamental nursing care, COVID-19, SARS-CoV-2, Missed care, Survey, Mixed methods
Background
Patient experience of care is associated with safety, clinical effectiveness, care quality, treatment outcomes, costs
and service use [1–5], and nursing care is a key determinant of this experience [6, 7]. Although nurses perform both generalist and specialist roles, all nurses are
involved in meeting patients’ ‘fundamental’ care needs.
Defining fundamental care has in the past been a contested area [8], but there is now greater consensus [9] in
that fundamental care can be described as ‘actions on
the part of the nurse that respect and focus on a person’s essential needs to ensure their physical and psychosocial wellbeing’ ( [9], p.2292). These needs are met
by developing a positive and trusting relationship with
the person being cared for as well as their family/carers
[10]. Therefore, the discrete elements of fundamental
care can be described as: actions to meet patients’ physical needs, and their psychosocial (wellbeing and mental
health) needs; these actions include nurses’ transactional
and relational behaviours [9].
The combination of SARS-CoV-2 symptoms and infectiousness of the SARS-CoV-2 virus may pose significant challenges for meeting patients’ physical and
psychosocial needs, as well as impacting on nurses’ relational and transactional care behaviours. Such challenges
may result in ‘missed care’ or ‘care left undone’, defined
as any aspect of nursing care that is omitted or delayed,
in part or in whole [11, 12]. Whilst our current study focuses specifically on fundamental nursing care, missed
care can therefore include areas of fundamental nursing
care (e.g. meeting patients’ hygiene needs) as well as
other areas of nursing care (e.g. discharge planning) [13].
Prior to the SARS-CoV-2 pandemic, both nurses and patients indicated that important elements of fundamental
nursing care are regularly missed, including nutrition,
hygiene (e.g. bathing; mouth care), ambulation/ supporting
mobility, communication/ talking with patients, and
emotional and psychological support [13–17]. The extent
of missed care is related to poor patient outcomes,
increased mortality and adverse events, and poor patient
satisfaction and experience of care [15, 18–20]. Factors contributing to missed care include high patient to registered
nurse ratios, associated lack of nurse time, patient dependency/ acuity, and the practice environment (e.g. managerial
support) [12, 16, 17, 21], and the likely impact of the SARSCoV-2 pandemic on all of these factors may further increase incidences of missed care. Indeed, we know from
nurses’ narrative accounts of the Canadian SARS outbreak
in 2003 that Personal Protective Equipment (PPE) [22],
time pressures [23] and visitor restrictions [24] can lead to
patients feeling abandoned by nurses [23].
Given the short time since the SARS-CoV-2 virus first
emerged in late 2019, knowledge of its impact on nursing care has been slow to emerge and as yet there is no
direct data on patients’ experience of nursing care. Most
of the research published to date has focussed on the
impact on nurses’ wellbeing, not on their processes of
caring. Thus, we know from surveys conducted in China
and Italy that front-line nurses have experienced huge
workload; long-term fatigue; infection threat; and anxieties and frustration concerning the death of patients for
families and vice versa [25]. A survey completed by 764
nurses (60.8%) and 493 physicians (39.2%) from 34 hospitals in China reported symptoms of depression (634
[50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]),
and distress (899 [71.5%]) amongst the health care
workers. Nurses, frontline health care workers, female
health care workers, and those working in Wuhan, reported more severe mental health symptoms than other
health care workers [26]. Nurses in Italy reported PostTraumatic Stress Disorder symptoms, severe depression,
anxiety, insomnia and perceived stress [27], and UK
nurses were concerned about the risks of SARS-CoV-2
on their physical and mental health, as well as the health
of their families [28, 29].
Sugg et al. BMC Nursing
(2021) 20:215
There is evidence emerging from the UK that these
effects on nurses, together with the rapid adjustment of
healthcare systems to accommodate the pressures of increased patient flow, redeployment of inexperienced staff
into isolation care environments, and other factors, may
have had a negative impact on patients. One survey on
recovered patients’ experiences at discharge found that
82% of respondents had not received post-discharge assessment visits, and 18% reported having unmet needs
[30]. Thus, the negative impact of the SARS-CoV-2 outbreak on nurses may in turn impact patients, acting as a
mediator of missed care. However, we do not currently
know if the concerns raised in the brief reports from the
Canadian SARS outbreak have been replicated or learnt
from in this current pandemic, and there are currently
no evidence-based guidelines for nursing patients with
SARS-CoV-2 who may be receiving ventilatory support
without tracheal intubation (i.e. not invasively ventilated), who represent the majority of hospitalised patients with this condition. This leaves nurses without
guidance and is potentially associated with variations in
patient experience, care quality and costs as redeployed
and/or inexperienced nurses struggle to adapt to
caring for patients in strict isolation [31] using unfamiliar
care procedures required for infection prevention and
control [32].
We designed the COVID-NURSE cluster randomised
controlled trial [33] to evaluate a fundamental nursing
care protocol for patients hospitalised with the SARSCoV-2 virus not invasively ventilated. The fundamental
nursing care protocol has been developed from three
main areas of activity: i) a survey of registered nurses’
and non-registered auxiliary nursing/ healthcare support
workers and assistants’ views and experiences of caring
for patients with SARS-CoV-2 including the barriers encountered in delivering fundamental care and strategies
adopted to overcome these; ii) a rapid systematic review
of the literature [34]; and iii) four co-creation workshops
involving nurses and patients with experience of being
hospitalised with the SARS-CoV-2 virus not invasively
ventilated, in which the findings from the survey and the
systematic review were presented and discussed.
In this paper, we report the findings from the survey
of nurses that relate to their views and experiences of
missed fundamental care and barriers to fundamental
care for inpatients with SARS-CoV-2 not invasively ventilated. We will report findings on strategies used to
overcome the barriers to care in a future article, to avoid
potential contamination of the trial before completion.
Methods
Aim and design
Our aim was to identify the views and experiences of
registered nurses and non-registered nursing care staff
Page 3 of 17
on missed fundamental care and the barriers to fundamental care for inpatients with the SARS-CoV-2 virus
not invasively ventilated. We conducted a cross-sectional
study employing a mixed methods explanatory design
[35] guided by a pragmatic philosophy [36]. For the
quantitative and qualitative components, we collected
data concurrently and analysed data sequentially (with
qualitative data analysed in order to explain the quantitative data). We gave the quantitative component greater
priority as this guided our analysis of qualitative data,
and we mixed the components during data analysis. This
approach enabled us to utilise the qualitative data to
elaborate on, clarify, illustrate and contextualise the key
quantitative findings [37, 38].
Participants and recruitment
Eligible respondents were UK-based registered nurses
and non-registered auxiliary nursing/ healthcare support
workers/ assistants that had actively engaged in nursing
inpatients with the SARS-CoV-2 virus who were not invasively ventilated. Thus, respondents who had nursed
patients who were not ventilated, or patients who received non-invasive ventilation, were eligible; respondents who only nursed invasively ventilated patients
were ineligible. We invited a convenience sample of
respondents using a range of strategies; including a database of nurses who had consented to be approached for
SARS-CoV-2 related research studies through their involvement in the ‘Impact of COVID-19 on the Nursing
and midwifery workforce’ (ICON) study [29]; networks
of senior research, management and clinical nurses in
England and Wales including contacts within the
National Institute for Health Research (NIHR) 70@70
research network, the Association of UK Lead Research
Nurses, the Royal Colleges, and hospital sites affiliated
with the COVID-NURSE Trial co-investigators; the UK
NIHR Clinical Research Network; and through social
media including Twitter and University of Exeter channels. We aimed for our survey distribution channels to
be as inclusive as possible in terms of encouraging
responses from nurses working in different types of
hospitals, including general vs. specialist, which were
geographically diverse and serving populations of different ethnicities.
We sent a link to the survey to nurses on our database
and to key gatekeepers in the networks listed above. We
emails and other communication channels appropriate
to their networks with a covering letter informing potential respondents of the purpose and timeframe for the
survey. The landing page for the survey provided links
to the participant information sheet, frequently asked
questions, and the survey. As this was an exploratory
study to guide our intervention development, within the
Sugg et al. BMC Nursing
(2021) 20:215
specific time limits of the COVID-NURSE trial and thus
using a convenience sampling frame, we did not have a
predetermined sample size calculation and sought to
recruit as many respondents as possible during the timeframe of the survey.
Data collection and materials
The survey was open for 3 weeks, plus 3 days to respondents who had commenced the survey, to provide the opportunity to complete it. We developed the survey with
input from the COVID-NURSE trial Co-Investigators and
members of the wider research team, in response to formal and informal feedback from four nursing teams who
piloted the survey, and in line with comments from the
University of Exeter Medical School Ethics Committee. At
all times in the development of the survey we involved
members of our patient and public involvement group
(PPI) including our PPI co-investigators and trial management group member, who gave us advice on the survey
design. Using Qualtrics™ online survey software [39], we
designed a bespoke online series of survey questions
including demographic items. We structured our survey
according to the Fundamentals of Care model [8, 9]. We
included three sections on physical, relational and psychosocial areas of care, and subsections in each of these areas
corresponding to sub-categories of care as adapted from
Feo et al. (2018) [9] (Table 1).
In each subsection (Table 1), we asked respondents to:
 Rate how well they thought they were able to meet
Page 4 of 17
(excluding those who had been invasively ventilated)
compared to their ability to meet the needs of other
patients they were experienced in nursing before
SARS-CoV-2. For example, for section one (physical
care), subsection one, respondents were asked to
rate how well they were able to meet the hygiene,
personal cleansing and toileting needs of patients
with the SARS-CoV-2 virus (excluding those who
had been invasively ventilated) compared to their
ability to meet the hygiene, personal cleansing and
toileting needs of other patients they were
experienced in nursing before SARS-CoV-2.
point Likert-type scale with the following options:
much better than, a little bit better than, the same
as, a bit worse than, or much worse than.
Alternatively, respondents could indicate that they
were not involved in this area of care;
 Provide free text to narratively identify and describe
examples of missed fundamental care;
 Select all relevant barriers to fundamental care from
a list provided. The barrier list was derived from
discussions with the COVID-NURSE trial CoInvestigators with expertise in nursing. Barriers were
standardised across all sub-categories, with
specific category. A list of barriers available for each
sub-category is provided in Additional file 1;
 Provide free text to narratively identify and describe
examples of barriers to fundamental care.
the needs of patients with the SARS-CoV-2 virus
Data analysis
Table 1 Survey structure; fundamental care areas and subcategories of care
Section: Care area
Subsection: Sub-category of care
1. Physical
1. Hygiene, personal cleansing and toileting
2. Eating and drinking
3. Rest and sleep
4. Mobility
5. Patient comfort
6. Patient safety
7. Medication management
2. Relational
1. Establishing a relationship with patients
2. Talking and listening
3. Non-verbal communication
4. Shared decision-making
5. Communicating with relatives, carers and
significant others
3. Psychosocial
1. Dignity and respect
2. Respecting patients’ values and beliefs
3. Wellbeing, anxiety and depression
The UK Clinical Research Collaboration (UKCRC)-registered University of Exeter Clinical Trials Unit received,
cleaned and processed the data, and uploaded datasets
to Microsoft Excel [40]. We applied pairwise deletion to
each survey item in order to maximise the data available,
and reported all percentages as the percentage of the
total number of respondents who provided data for that
survey item. We combined ethnicity data into standard
categories [41].
Quantitative data analysis
We analysed quantitative data, including demographic
data, descriptively. For respondents’ ratings of care, we
combined responses into four categories for ease of interpretation: 1) better than other patients (combining
‘much better’ and ‘a little bit better’); 2) the same as
other patients; 3) worse than other patients (combining
‘much worse’ and ‘a bit worse’); 4) not involved in this
area of care. For both ratings of care and barriers to
care, we calculated the frequency, and percentage, of respondents selecting each option for each sub-category of
care. We also calculated the percentage of respondents
Sugg et al. BMC Nursing
(2021) 20:215
selecting each barrier in total across each of the three
care areas (physical; relational; psychosocial).
Qualitative and mixed methods data analysis
We achieved familiarisation with the data through reading
survey responses and analysed data using Framework
Analysis [42] to allow for both inductive and deductive approaches in combining our study aims/ survey questions
with participants’ original accounts [42, 43]. In undertaking qualitative analysis within our explanatory mixed
methods design, we focused on explaining the key quantitative findings rather than completing a full, independent
analysis of qualitative themes, so that we could understand
respondents’ meanings in providing their quantitative
responses and focus in on qualitative examples in key
problem areas indicated by the quantitative data.
Data interpretation and the development of analytic
categories were discussed by a multidisciplinary team
trained in qualitative data analysis and consisting of five
researchers (HVRS, A-MR, HI-S, DAR, NM) with backgrounds in nursing (3), nursing education (3), mental
health services research (2) and clinical research (2). The
team was led by HVRS; A-MR, HI-S, NM and HVRS independently coded subsets of the raw data; HVRS
double-coded and verified subsets of the data coded by
A-MR, HI-S and NM.
For missed care and barriers, we separately coded
responses into a framework structured according to the
Fundamentals of Care Framework. Within each subcategory of care, we analysed survey responses thematically
using a constant comparison approach, and examined similarities and differences in respondents’ accounts in order to
categorise the examples of missed care and barriers for each
sub-category [44, 45]. For barriers to care, we then focused
our analysis on the main barriers highlighted by the quantitative data, categorising the qualitative findings across all
sub-categories of care into each of the top five rated barriers for each of the three care areas (physical; relational;
psychosocial). We have integrated the quantitative and
qualitative data in side-by-side comparison tables [35] organised by the quantitative data (for missed care, from highest
to lowest percentage of respondents rating the sub-category
of care as ‘worse’; for barriers to care, from highest to lowest percentage of respondents selecting the barrier). In
these tables we have included summaries of the qualitative
findings and quotes to illuminate these.
We describe our study in line with cross-sectional
study reporting guidelines (see Additional file 2 for completed STROBE checklist) [46].
Results
Respondent characteristics
From 3rd to 26th August 2020, 1062 eligible respondents consented to provide survey data; 84 of these
Page 5 of 17
provided no further data. The number of respondents
providing data for each survey item is provided in
Additional file 1. Respondent characteristics are summarised in Table 2.
Respondents’ views on missed fundamental care
Quantitative results
The percentage of respondents rating the physical,
relational and psychosocial care of patients with the
SARS-CoV-2 as worse, the same as, or better than other
patients, for each constituent sub-category of care, is
shown in Figs. 1, 2 and 3. Frequencies are provided in
For sub-categories of care across all three care areas
(physical, relational, psychosocial), a majority of
respondents rated their ability to meet the needs of
SARS-CoV-2 patients as worse than for other patients.
The following sub-categories were rated as worse by a
majority of respondents: ‘talking and listening’ (57%);
‘communicating with relatives, carers and significant
others’ (57%); ‘mobility’ (56%); ‘non-verbal communication’ (54%); ‘emotional wellbeing, anxiety and depression’
(53%). Just less than half (49%) of respondents also rated
‘establishing a relationship with patients’ as worse for
SARS-CoV-2 patients. For all the other physical subcategories (aside from ‘mobility’), approximately one
third or less of respondents rated care as worse for
SARS-CoV-2 patients (range 26–34%). For relational
care, almost one third of respondents (32%) rated
‘shared decision-making’ as worse for SARS-CoV-2 patients, and for psychosocial care ‘dignity and respect’ and
‘respecting patients’ values and beliefs’ were rated as
worse for SARS-CoV-2 patients by 26 and 19% of respondents respectively.
Integrated quantitative and qualitative results
In Tables 3, 4 and 5 we have presented side-by-side
comparison tables integrating the quantitative findings
and summarised qualitative findings on missed care for
each sub-category of physical, relational and psychosocial care. Respondents’ ID numbers are included in
brackets after quotes.
Between 26 and 56% of respondents struggled to
meet all sub-categories of patients’ physical needs efficiently and effectively compared to patients they would
normally care for. Particularly highlighted were restrictions on patients’ mobilisation outside of side (isolation)
rooms, and some respondents also described issues with
interrupted sleep; missed and delayed personal care, particularly mouth care; restrictions and delays in providing
food and drink; reductions in observing patients in side
rooms; errors and potential for errors, particularly
around medications; challenges with controlling symptoms of breathlessness and high temperature; missed
Sugg et al. BMC Nursing
(2021) 20:215
Page 6 of 17
Table 2 Respondent characteristics
Table 2 Respondent characteristics (Continued)
N (%)
Gender
Age
Ethnicity
Environment
Country
Main position
Redeployed?
Female
858 (87.7)
Male
112 (11.5)
Prefer not to say
8 (0.8)
< 25 98 (10.0) 26–30 173 (17.7) 31–40 257 (26.3) 41–50 234 (23.9) 51–60 182 (18.6) 61–66 26 (2.7) > 67
1 (0.1)
Prefer not to say
7 (0.7)
Asian/ Asian British
32 (3.3)
Black/ African/ Caribbean/
Black British
15 (1.5)
Mixed/ Multiple ethnic groups
13 (1.3)
Other ethnic group
46 (4.7)
Other White
85 (8.7)
White British
779 (79.7)
Prefer not to say
8 (0.8)
Acute General NHS hospital
including teaching hospital
898 (91.8)
Tertiary/ specialist
63 (6.4)
Private healthcare
6 (0.6)
Missing data
11 (1.1)
England
933 (95.4)
Wales
15 (1.5)
Scotland
5 (0.5)
Northern Ireland
4 (0.4)
Other country
1 (0.1)
Missing data
20 (2.0)
Charge nurse
206 (21.1)
Staff nurse
374 (38.2)
142 (14.5)
Research nurse
42 (4.3)
Nurse researcher
1 (0.1)
Manager
73 (7.5)
Student nurse
20 (2.0)
Non-registered nursing
associate
10 (1.0)
Non-registered care
or nursing assistant
90 (9.2)
Missing data
20 (2.0)
Yes
139 (14.2)
No
227 (23.2)
Missing data
612 (62.6)
N (%)
Usually work on
respiratory warda?
Usually work in
non-warda environment?
Yes
114 (11.7)
No
252 (25.8)
Missing data
612 (62.6)
Yes
138 (14.1)
No
228 (23.3)
Missing data
612 (62.6)
a
Ward: an inpatient division in a hospital typically shared by patients who
need a similar type of care. Non-ward: a non-residential health care setting
such as outpatient, community or primary care. Percentages may not always
total 100 due to rounding
pressure area care; and a lack of presence from multidisciplinary colleagues such as physiotherapists, dieticians
and pharmacists.
In relational care, the majority of respondents (57%)
highlighted communication difficulties with patients and
their significant others, with almost half of respondents
reporting that this impacted on their ability to establish
a relationship with patients. Respondents struggled to
build rapport with patients; experienced restrictions in
being heard, understood, and spending time with patients; and were less able to use facial expressions, nonverbal cues and touch to comfort patients. Respondents
reported that patients missed having visits from significant others, and they struggled to both keep significant
others informed and obtain information about patients
from them. A third of respondents also experienced
shared decision-making as more rushed and policy-led
than usual.
In psychosocial care, the majority of respondents
(53%) reported struggling to support patients’ emotional
wellbeing and mental health, typically prioritising
functional and physical care over emotional care. Most
respondents were unable to provide usual levels of
support, reassurance and interaction with patients, and
reported that patients experienced isolation, loneliness,
fear and low mood. A minority of respondents also had
difficulties maintaining patients’ privacy and dignity,
such as drawing curtains for personal care or distressing
scenes; lacked knowledge about patients’ beliefs; and
noted a lack of presence from psychological services and
chaplaincy.
Respondents’ views on barriers to fundamental care
Quantitative results
We summarise the percentage of respondents selecting
each barrier in Table 6 (presented as the average percentage of respondents selecting the barrier, and the
range of respondent percentages, across the constituent
sub-categories of physical, relational and psychosocial
care; where the barrier was only an option for one subcategory, we just present the percentage of respondents
Sugg et al. BMC Nursing
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Page 7 of 17
Fig. 1 Respondents’ ratings of meeting the physical care needs of patients with SARS-CoV-2
selecting the barrier for that sub-category). We have
listed barriers in the order of most to least frequently selected across all care areas. We have provided the number of respondents selecting each barrier for each subcategory of care in Additional file 1.
In total, eight barriers were ranked within the top five
in at least one of the three care areas (Tables 7, 8 and 9).
‘Wearing PPE’, and the ‘severity of the patient’s condition’ were the most frequently selected barriers and were
among the top five barriers to all three care areas. The
third most frequently selected barrier, ‘difficulties taking
items/ equipment in and out of isolation rooms’, was
among the top five barriers to physical care. ‘Lack of
time’, the fourth most frequently selected barrier, was
among the top five barriers to both psychosocial and relational care. ‘Lack of personnel, skill mix, catering,
housekeeping or dietetic support’, the fifth most frequently selected barrier, was among the top five barriers
to both physical and psychosocial care. The sixth most
frequently selected barrier, ‘lack of knowledge about
COVID-19’, was among the top five barriers to both relational and psychosocial care. The seventh most frequently selected barrier, ‘not enough physical resources
such as equipment/ washing facilities/ stock items’, was
the final top five barrier to physical care. The eighth
most frequently selected barrier, ‘fear of catching
COVID-19’, was the final top five barrier to relational
care.
Integrated quantitative and qualitative results
In Tables 7, 8 and 9 we report the top five barriers per
care area in order of highest to lowest percentage of respondents selecting this barrier across the constituent
sub-categories. We also include the sub-category for
which the highest percentage of respondents selected
the barrier in that care area, and then integrate the
qualitative data in side-by-side comparison tables. Respondents’ ID numbers are included in brackets after
quotes.
Respondents struggled to meet the physical care needs
(particularly rest and sleep, mobility, eating/drinking,
and personal care) of patients who were very unwell,
often attached to oxygen equipment, and with high
monitoring requirements. Wearing PPE also created a
physical barrier to meeting such needs, particularly hygiene needs. A lack of storage and stock supplies in
Sugg et al. BMC Nursing
(2021) 20:215
Fig. 2 Respondents’ ratings of meeting the relational care needs of patients with SARS-CoV-2
Fig. 3 Respondents’ ratings of meeting the psychosocial care needs of patients with SARS-CoV-2
Page 8 of 17
Sugg et al. BMC Nursing
(2021) 20:215
Page 9 of 17
Table 3 Side-by-side comparison of quantitative and qualitative data on missed physical care
Care category (%
rating care as
worse)
Summary of qualitative data on missed care
Quotes demonstrating qualitative data
Mobility (56%)
Patients in side roomsa were unable to mobilise by moving freely
on the ward and walking to the toilet. Patients were also unable
to access facilities such as the gym or garden, or complete stair
assessments. Pressure area care and rehabilitation could be
missed, and respondents experienced a lack of physiotherapy
presence/ support.
“Due to needing to isolate … one of our patients was in
his room for 4 weeks.” (ID581)
“Physios would leave C19+ patients to be seen at the end
of the day, resulting in a shortened session or missed
session.” (ID244)
Rest and sleep (34%) Patients often experienced sleep which was interrupted by
consistent monitoring/ observations and interventions, and by
noise and lights. Patients also experienced a lack of time for
sleep, difficulties settling, and poor quality sleep.
“There was not much “down time” during the night.”
(ID585)
“It was so busy that we couldn’t even switch off the lights
… sleep deprivation was present on every night shift.”
(ID355)
Patient safety (34%)
Respondents highlighted a reduction in monitoring/ observing
patients who were in closed bays or side rooms, and a related
increased risk of falls. Respondents also noted various errors and
potential for errors, such as medication errors and failures to
escalate, and that regular skin checks could be missed.
“Need to isolate patients into side rooms was treated
(rightly or wrongly) as more important than their risk of
falls.” (ID286)
“Medication rounds not done next to patient. Nursing staff
not present in the bays so often.” (ID512)
Eating and drinking
(33%)
Respondents noted issues with food/drink supplies such as
running out of drinks, lack of choice for patients, and difficulties
for patients eating using plastic plates/cutlery. There were some
delays in providing food and drink to patients, and between
meals these needs could be missed. Some patients were
weighed less regularly and some respondents experienced less
presence from dieticians.
“Poor nutritional intake for those most vulnerable. Missed
regular cups of tea … Gut-wrenching as a nurse.” (ID20)
“Tea trolleys and meal choices were much harder to
facilitate. It took longer for diet and fluid to get to
patients.” (ID262
Patient comfort
(32%)
Symptom control was challenging, particularly breathlessness and
temperature, and oxygen equipment was uncomfortable. Patients
missed having visitors, and interaction/ time with nurses, which
affected their comfort levels. Respondents also noted that nursing
patients in the prone position (‘proning’) and difficulties turning
patients meant pressure area care could suffer.
“Patients were uncomfortable due to nature of condition,
positioning (extended time prone giving them sore joints
or back).” (ID475)
“Unable to comfort emotionally distressed patients due to
PPE. Lack of family support.” (ID464)
Hygiene, personal
cleansing and
toileting (27%)
Patients’ personal care could be missed or delayed, particularly
mouth care, but also washes, hair brushing and toileting. Less
time was spent on personal hygiene, with some patients
expected to meet these needs themselves yet not encouraged to
do so. Patients’ rooms were also cleaned less often, and patients
often couldn’t access private bathrooms.
“Delayed response to washes, often flowing into
afternoon.
Personal care, oral care, often missed completely.” (ID20)
“Less assistance. Patient left or expected to meet most
hygiene needs themselves and not pushed or encouraged
to do this.” (ID130)
Medication
management (26%)
Some staff were unable to double check medications and some
reported an increase in medication errors. There could be delays
in receiving and administering medications, and some
respondents ran out of medications. Respondents also
experienced a lack of pharmacist presence/support.
“I made my first medication error during the pandemic…
Thankfully no one was hurt, but it still haunts me.” (ID529)
“Medications were not available … Pharmacists refused to
come to the wards.” (ID703)
a
Side rooms: rooms in which individual patients stay in isolation from other patients
SARS-CoV-2 areas, and the increased need to clean
items between uses, meant insufficient supplies for respondents to meet patients’ needs and make them comfortable. The need to don and doff PPE upon entering
and leaving a patient’s room delayed responding to patients’ needs, meant staff had to try to prepare all items
needed in the room before entering, and created difficulties providing patients with items such as food and
drinks. Respondents also experienced staff shortages and
a lack of presence from specialised services which increased their own workloads, and compromised patients’
care and safety.
Wearing PPE created a very significant barrier to relational care and communicating with patients, compromising hearing, lip reading, seeing facial expressions, use
of non-verbal cues and touch. PPE also made staff difficult to recognise. Due to staff shortages and high patient
acuity, respondents had little time to spend talking and
listening to patients, prioritising a functional approach
to care. This was compounded by respondents’ reluctance to spend time in patients’ rooms due to fear of
catching SARS-CoV-2, which limited their ability to establish a relationship with patients. Patients’ ability to
communicate and participate in decision-making was
also compromised by the severity of their own conditions, and respondents felt they lacked the knowledge of
SARS-CoV-2 required to answer patients’ questions during the decision-making process in particular. Running
through these accounts was the impact of restrictions on
visitors, for both patients’ wellbeing and staff’s ability to
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Table 4 Side-by-side comparison of quantitative and qualitative data on missed relational care
Care category (% rating Summary of qualitative data on missed care
care as worse)
Quotes demonstrating qualitative data
Talking and listening
(57%)
Many respondents highlighted a lack of rapport building
with patients, and lack of clear communication with
patients (i.e. being heard and understood), specifically
noting the inability to lip read through PPE. Related to this,
respondents stressed reductions in nurse-patient contact,
including both physical touch and time spent with patients.
“Wearing PPE especially masks meant that patients often
could not hear you and you would have to repeatedly talk
to them which made conversation and flow more difficult.”
(ID328)
“You can’t hear properly with shields. You can’t see
properly. I lip read as well as listen, this is very difficult.
Verbal [communication] is difficult with softly spoken
patients.” (ID505)
Communicating with
relatives, carers and
significant others (57%)
Patients missed having visits from significant others and
were accordingly isolated. Staff had less opportunity to
build relationships with significant others and manage their
emotional needs, and noted that significant others were
not always updated in a timely and regular manner. Staff
experienced difficulties keeping significant others fully
informed over the phone whilst ensuring confidentiality
was maintained.
“Patients struggled with lack of family contact.” (ID573)
achieved.” (ID427)
“It has also been difficult building a rapport with families
and relatives… This has added difficulty as they are unable
to see the environment their loved one is being care in.”
(ID579)
Non-verbal
communication (54%)
Staff were less able to communicate with patients using
facial expressions, non-verbal cues, physical gestures and
touch. Some respondents therefore felt that they were
showing less comfort, reassurance, empathy and friendliness towards patients. They also had a reduced ability to
pick up on patients’ non-verbal cues and respond to their
needs accordingly.
“Patients unable to read facial expressions, see non-verbal
cues, see the nurse was being empathetic and compassionate to their needs as they were unable to see nurse’s faces.”
(ID332)
“Visitors (who normally pick up on missed cues) unable to
visit.” (ID204)
Establishing a relationship Some respondents highlighted the same issues as
with patients (49%)
experienced in relation to ‘talking and listening’, also noting
that it was harder to get to know these patients; that
functional care could be prioritised over relationship
building; and that they missed opportunities to obtain
information about patients from their significant others as
usual.
“The human aspect of nursing care. Not being able to
smile. To sit and make a cup of tea and listen to the
patient’s opinion of how their stay was going. Every aspect
of nursing became clinical.” (ID20)
“Difficult to hear and communicate whilst wearing PPE,
therefore loss of personal touch.” (ID585)
Shared decision-making
(32%)
“Due to nature of virus decisions were often made in
patients’ best interests, without being able to discuss them
with patient or family.” (ID204)
“It was decided that all patients over a certain age would
be DNAR, it was hard to justify this.” (ID368)
Some respondents experienced decision-making as more
rushed and policy-led (e.g. escalation/ resuscitation plans)
with somewhat less involvement from the patient and significant others. Staff were also less equipped than normal
with the knowledge required to answer patients’ questions
and provide information during decision-making.
DNAR Do Not Attempt Resuscitation
Table 5 Side-by-side comparison of quantitative and qualitative data on missed psychosocial care
Care category (%
rating care as
worse)
Summary of qualitative data on missed care
Quotes demonstrating qualitative data
Emotional wellbeing,
anxiety and
depression (53%)
Respondents noted that patients’ physical care was prioritised over
their emotional needs. Staff were unable to provide normal levels
of support e.g. skin to skin touch; time for communication and
listening. Patients experienced isolation; and little interaction with
staff, significant others, or other patients. Respondents observed
fear and low mood across patients, and were unable to reassure
patients with knowledge about the virus/ treatments. Respondents
also noted a lack of presence/support from psychological services.
“Some days it was just task orientated and we just needed to get
to the end of the shift without anyone dying.” (ID593)
“We weren’t able to even give a patient a hand to hold that didn’t
have a glove on it and a face covered in a mask.” (ID354)
“Unable to refer patients to psychology for support or to have
relatives to visit or for patients to go outside.” (ID196)
Dignity and respect
(26%)
Some respondents reported experiencing difficulties maintaining
privacy and dignity for patients, such as closing curtains when
performing personal care. Patients who would normally use the
hospital gowns rather than their own clothes. Proning patients
was also considered undignified, and some respondents
experienced patients dying in bays with no privacy.
“A lack of space, and having often 2 patients in one bedspace
screens, but nowhere near enough.” (ID377)
“Proning can be undignified due to the nature of the positioning
and amount of people it requires to undertake.” (ID585)
“Patients dying next to them was very distressing.” (ID298)
Respecting patients’
values and beliefs
(19%)
Some respondents noted a lack of knowledge of patients’ beliefs
as patients were unable to inform them and/or significant others
were not present to guide them. Respondents experienced a lack
of chaplaincy support on the wards. Patients were also unable to
leave their rooms to visit the prayer room/ chapel, and could not
access family/community support as they normally would.
“We didn’t have chaplaincy visiting. We weren’t able to spend
time with our dying patients in the same way. We didn’t always
know the patient’s spiritual or religious beliefs. We often didn’t
know much at all about them.” (ID354)
“Patients from certain cultures were unable to behave in the usual
way due to restrictions.” (ID487)
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Table 6 Percentage of respondents selecting each barrier to care (average and range across sub-categories)
Barrier
Physical Care
Relational Care
Psychosocial care
Wearing PPE
33% (21–44%)
61% (37–77%)
44% (36–48%)
Severity of the patient’s condition
41% (33–50%)
29% (21–47%)
37% (35–39%)
Difficulties taking items / equipment in and out of isolation rooms for
patients nursed in these environments
38% (28–54%)
13% (9–18%)
17% (13–21%)
Lack of time
22% (12–29%)
31% (24–41%)
37% (30–40%)
Lack of personnel, skill mix, catering, housekeeping or dietetic support
30% (11–38%)
12% (9–17%)
24% (20–27%)
23% (13–34%)
16% (8–28%)
25% (18–30%)
Not enough physical resources such as equipment/washing facilities/
stock items e.g. water jugs, disposable cups, patients’ teeth
24% (12–28%)
12% (4–34%)
14% (10–19%)
Fear of catching COVID-19
21% (13–30%)
19% (11–25%)
23% (22–24%)
Frequent changes in hospital, Trust or organizational policies
22% (15–35%)
12% (7–20%)
15% (14–15%)
Lack of appropriate PPE
17% (11–26%)
8% (5–11%)
10% (10%)
Lack of ability to establish a meaningful rapport with the patient
9% (5–17%)
15% (12–22%)
14% (11–19%)
Lack of information about the ward or patient
10% (6–14%)
9% (7–11%)
16% (12–24%)
Competing requirements of essential medical interventions
15% (13–20%)
9% (4–11%)
11% (10–13%)
Lack of ability to regulate the environment (noise level, lighting,
remote monitoring)
42% (34–49%)
N/A
N/A
Lack of relevant personal expertise
11% (6–16%)
7% (4–11%)
11% (9–12%)
Lack of personal psychological support
7% (5–10%)
7% (5–10%)
11% (7–17%)
Lack of personal emotional capacity
6% (2–9%)
7% (5–10%)
9% (7–14%)
9% (6–17%)
4% (2–5%)
5% (4–7%)
Lack of leadership from senior nurses or managers
8% (5–13%)
6% (3–9%)
8% (7–10%)
Lack of privacy for the patient
51%a
N/A
N/A
Inability to meet the patient’s dietary requirements
13%a
N/A
N/A
Other
5% (3–7%)
5% (2–17%)
7% (6–9%)
a
No range provided as barrier only offered as an option for one sub-category of care
communicate with significant others, particularly in the
context of a lack of time to update significant others remotely and consult on time critical decision-making.
Respondents experienced similar barriers to psychosocial care as to relational care, including the impact of
restrictions on visitors. Patients’ wellbeing and staffs’
ability to create therapeutic relationships suffered as a
result of the barriers to communication presented by
PPE. Again, staff had limited time to spend supporting
patients’ emotional and spiritual needs; patients’ abilities
to communicate their needs and beliefs were compromised by the severity of their conditions; and staff found
it difficult to answer patients’ questions about SARSCoV-2 or provide them with reassurance. The lack of
SARS-CoV-2 knowledge also caused fear and anxiety for
patients. Respondents experienced a lack of presence
from psychology services and chaplaincy which limited
support for patients, and some lacked the expertise to
support patients’ psychological needs.
Discussion
In this survey, we found that respondents rated their
ability to meet patients’ needs in many areas of
fundamental care as worse for hospitalised patients with
SARS-CoV-2 than for other patients they were experienced in caring for before the pandemic. Although
meeting patients’ needs was rated by some respondents
as worse in all areas of care; the majority of respondents
specifically identified mobility; talking and listening;
non-verbal communication; communicating with relatives, carers and significant others; and caring for patients’ emotional wellbeing, anxiety and depression as
poorer. Across the categories of physical, relational and
psychosocial care, we found the strongest reports of difficulties were with undertaking relational care, with the
majority of respondents rating their ability to meet patients’ needs as worse in three of the five categories. In
contrast, although 26–34% of respondents rated elements of physical care as worse, it was only for mobility
that the majority (56%) cited deficits in this care area
specifically. For psychosocial care, most respondents
thought that their ability to meet patients’ needs was at
least as good or better in the areas of respect, dignity,
values and beliefs but this contrasts with more than half
reporting that their ability to address patients’ emotional
wellbeing, depression and anxiety needs was poorer.
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Table 7 Integration of quantitative and qualitative data on top five barriers to physical care
Barrier (% selecting
barrier)
Highest subcategory (%
selecting
barrier)a
Experiences/ explanations of barriers (from
qualitative data)
Quotes demonstrating qualitative data
Severity of the patient’s
condition (41%)
Rest and sleep
(50%)
Patients were often fatigued, weak, breathless,
bedbound, proned, and had high oxygen
requirements. These factors caused discomfort,
limited patients’ ability to voice their needs,
impeded mobility, interfered with eating/drinking,
and restricted staffs’ ability to provide personal
care (e.g. bathing; mouth care). The need for
frequent monitoring also interrupted patients’ rest.
“CPAP hood made eating and drinking
opportunities limited … Their rest and sleep was
broken to perform essential care.” (ID988)
“The priorities had to change due to maintaining
organ functions that were in critical states and
personal care had to be pushed down the priority
list.” (ID92)
Difficulties taking items/
equipment in and out of
isolation rooms (38%)
Eating and
drinking (54%)
Staff spent extra time cleaning items which had
entered patients’ rooms, and struggled to prepare
all items ready to take in to avoid donning and
doffing PPE. Specific difficulties included providing
meals/drinks and equipment to support mobility,
removing plates/trays and waste products, and
not being able to take drug charts into rooms.
“There was a big time lag of having to don and
doff in and out of rooms if you forgot a flush, or
needed another syringe.” (ID20)
“The rooms for isolated patients were very small
and taking equipment in and out and cleaning
equipment … was very time consuming.” (ID456)
Wearing PPE (33%)
Hygiene,
personal
cleansing and
toileting (44%)
Respondents struggled to meet patients’ physical
needs, especially personal care and moving/
turning patients, whilst wearing PPE which was
hot, difficult to see through, and created a
physical barrier. Changing PPE between patients
took time away from meeting their needs, and
donning PPE delayed responding to patients’
requests.
“PPE gear has made delivery of any nursing care
so much harder, just by the uncomfortable
wearing of the masks, vision obscured by visas or
goggles and the heat.” (ID590)
“Requirement to wear PPE competes with need to
provide assistance promptly.” (ID286)
Lack of personnel, skill
mix, catering,
housekeeping or dietetic
support (30%)
Patient safety
(38%)
Respondents noted a lack of physiotherapists,
dieticians, pharmacists and domestic staff, which
delayed patient care. Nursing staff shortages were
stressed, which meant insufficient staff for tasks
such as mobilising patients and performing
personal care. Redeployed staff could also lack
knowledge of equipment, medications and the
importance of fundamental care.
“Pharmacists did not visit the ward and they are
normally there to support and order drugs so it
was another thing that we had to do” (ID83)
“We had plenty of redeployed staff but not always
staff that were able to be hands on as they had
not been clinical for many many years.” (ID179)
Not enough physical
resources such as
equipment (24%)
Patient comfort
(28%)
Respondents reported shortages of items
including feed pumps, chairs, hoists, food, hot
drinks, bottled water, weighing equipment,
curtains, commodes, soap, wipes, medications and
PPE. This was related to a lack of storage in
COVID-19 areas, inability to share items with other
areas, and need to clean items between uses. This
impeded patient mobilisation and the timely completion of tasks.
“Chronic shortage of pretty much everything.”
(ID80)
“Simple things like a tray to take food in to
isolation rooms in short supply” (ID98)
“Lack of specialist equipment on COVID wards
(due to storage or lack of enough equipment to
a
Highest sub-category = sub-category for which the highest percentage of participants selected the barrier
Respondents identified clear reasons why they
thought these elements of care were worse for these patients. Foremost was infection control, specifically the
wearing of PPE and nursing patients in isolation. PPE
was cited as a barrier to relational care by twice as
many respondents as any other barrier. It was uncomfortable for respondents, created a barrier to providing
physical care, and impeded verbal and non-verbal communication. Insufficient stock, and staffs’ inability to
take items in and out of isolation rooms without donning and doffing PPE, were also significant barriers to
physical care. These barriers were compounded by the
severity of the patient’s condition, requiring as it did
the use of oxygen equipment, proning (nursing patients
in the prone position), and causing patients’ difficulties
in communicating when breathless and/or sedated.
Another top five barrier to physical and psychosocial
care was the lack of presence from specialist services,
and a lack of expertise in redeployed staff themselves.
Time, or the lack of it, prevented respondents from
talking and listening to patients, although another
highly cited barrier was staffs’ own reluctance to spend
time with patients for fear of catching SARS-CoV-2
themselves. This was compounded by a lack of knowledge
about SARS-CoV-2 which impeded respondents’ ability to
answer patients’ questions. Throughout their accounts, respondents noted the impact of restrictions on visitors for
both patients and nursing staff. This series of barriers conspired to mean that nurses largely focused on the functional, physical aspects of care, with relationship-building
and addressing patients’ emotional wellbeing becoming a
secondary priority.
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Table 8 Integration of quantitative and qualitative data on top five barriers to relational care
Barrier (%
selecting
barrier)
Highest subcategory(% selecting
barrier)a
Experiences/ explanations of barriers (from
qualitative data)
Quotes demonstrating qualitative data
Wearing PPE
(61%)
Non-verbal
communication (77%)
Wearing PPE impeded respondents’ abilities to
communicate with patients and build a rapport with
them. It was difficult to hear and be heard and
understood through PPE; not possible for patients to
lip read; and not possible for staff to communicate
using non-verbal cues, facial expressions/ smiles,
physical gestures or physical touch. PPE also hid
staffs’ names, made them harder to recognise, and
caused fear for some patients.
“The reduction in the human aspect of nursing,
being wrapped in plastic and shouting at people
(ID20)
“It was so difficult to comfort without touch. It was
quite alien really.” (ID479)
“We would be very scary to patients in the
beginning, as they were not used to staff being in
Lack of time
(31%)
Communicating with
Due to staff being off sick, many patients being very
relatives, carers and
unwell, and increased workloads, respondents were
significant others (41%) often too busy to sit with, talk and listen to patients,
and prioritised a functional approach to care.
Clustering care, and minimising time spent in
patients’ rooms, also meant that staff spent less time
with patients. Respondents also lacked time to
contact and update patients’ significant others.
“Due to the pressures of the pandemic on staffing
and resources sometimes it was hard to spend as
much time talking to the patients as would be
desired.” (ID618)
“Not being able … to sit and make a cup of tea and
listen to the patient’s opinion of how their stay was
going. Every aspect of nursing became clinical.”
(ID20)
Severity of the Shared decisionpatient’s
making (47%)
condition
(29%)
Patients were often sedated, using oxygen
equipment or experiencing delirium, which made it
difficult for them to communicate, understand their
care, be involved in decision-making, and contact
significant others. Visitor restrictions due to the nature of COVID-19 meant that staff could not get to
know patients through their significant others.
“Patients were sedated so unable to make
relationships with them. When they were awake a
lot experienced delirium.” (ID851)
“There were many times when patients were not
well enough and deteriorating so rapidly that we
did not really have the time to explain every
available option.” (ID377)
Fear of
catching
COVID-19
(19%)
Establishing a
relationship with
patients (25%)
Respondents were reluctant to get physically close
to patients, and to enter or spend time in their
rooms, for fear of contracting COVID-19. They were
often advised to minimise time in the patient’s room.
Some respondents noted that the quality of PPE did
not seem adequate, which led to further fear of contracting COVID-19.
“Peoples’ fear of catching covid meant they rushed
time with the patient and didn’t engage with them
as much.” (ID558)
“Inadequate PPE meant I didn’t want to stay in
room for longer than necessary therefore I didn’t
spend extra time getting to know the patient.”
(ID160)
Lack of
knowledge
Shared decisionmaking (28%)
Respondents could lack sufficient knowledge of
COVID-19 to provide patients with reassurance and
outcomes as much as they usually would. This impeded building a rapport with patients and shared
decision-making.
“[It was] challenging to reassure them and build a
rapport with them, particularly when we couldn’t
give them much information on the condition or its
management (due to general limited knowledge).”
(ID465)
a
Highest sub-category = sub-category for which the highest percentage of participants selected the barrier
Our results support previous work in related areas.
With previous studies suggesting that fundamental
nursing care is already regularly missed in the areas
of mobility, communication and talking with patients,
and providing emotional and psychological support
[13–17], our findings highlight the further impact of
the SARS-CoV-2 virus on meeting patients’ needs in
these particular areas. Consistent with previous
explanations for missed care prior to the pandemic
[12, 16, 17, 21], respondents highlighted patient acuity
and lack of time as barriers to meeting patients’
needs, amongst other challenges more specific to the
pandemic context.
Respondents’ accounts of the impact of wearing PPE
on communication and the development of therapeutic
relationships with patients, and the impact of restrictions
on visitors for patients’ emotional wellbeing at a time
when nurses themselves struggled to meet these needs
due to time pressures and PPE, reflect nurses’ nonempirical accounts of the Canadian SARS outbreak in
2003 [22–24]. Our findings concur with nurses’ reports
of high workloads and their fears regarding the risks
posed by SARS-CoV-2 to themselves [25, 28, 29].
Respondents’ accounts regarding the impact of these
factors are consistent with the reports of patients themselves, who may experience poor communication, a lack
of support and assistance, and insufficient information
and/or equipment [30]. In addition, relatives, carers and
significant others can experience poor communication
from hospital staff and may not be kept well informed
about the patient [30]. Indeed, our findings regarding
respondents’ lack of knowledge about SARS-CoV-2 for
providing patients with information, the barriers they
report to communication with both patients and their
significant others, and the lack of supplies reported may
help to explain such experiences.
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Table 9 Integration of quantitative and qualitative data on top five barriers to psychosocial care
Barrier (% selecting
barrier)
Highest subcategory (%
selecting
barrier)a
Experiences/ explanations of barriers (from
qualitative data)
Quotes demonstrating qualitative data
Wearing PPE (44%)
Emotional
wellbeing,
anxiety and
depression (48%)
Wearing PPE limited verbal and non-verbal communication, rapport building, and physical contact
with patients, which impacted on patients’ wellbeing and staffs’ abilities to develop therapeutic
relationships and meet patients’ emotional needs.
Seeing staff in PPE and being unable to recognise
them caused discomfort.
“Wearing full PPE impaired the creation of a
therapeutic relationship with the patient. Both
patient and staff become de-personalised.”
(ID443)
“It must have been terrifying for the patients who
did wake up seeing us in our full PPE.” (ID80)
Lack of time (37%)
Emotional
wellbeing,
anxiety and
depression (40%)
In the context of visitor restrictions, respondents
experienced more pressure to provide emotional
care to patients, but less time to do so as wards
were so busy. Staff had little time to sit with
patients, provide support, understand their values
and beliefs, and attend to their emotional and
spiritual needs. They were also reluctant to spend
much time in patient rooms or advised not to.
“In critical care we are used to providing the
emotional and psychological support needed, but
… Covid critical care being busier than usual
caused a lot of constraints to do this.” (ID229)
“Lack of time would be the main factor as staff
couldn’t fully engage with the patient to
understand their beliefs and wishes.” (ID85)
Severity of the patient’s
condition (37%)
Dignity and
respect (39%)
As many patients were sedated, ventilated and/or
short of breath, staff had little opportunity to
communicate with them, develop a rapport,
assess their emotional/spiritual needs, or find out
their wishes and beliefs. Patients and respondents
were at times aware when they were likely to die
which was overwhelming for all involved.
“The patients were unable to voice their needs.”
(ID268)
“Patients’ anxieties were difficult to assess at
times.” (ID627)
“Difficult to establish a rapport with patients as
they were so short of breath/wearing CPAP
masks, therefore difficult to know what their
values/ beliefs are.” (ID585)
COVID-19 (25%)
wellbeing,
anxiety and
depression (30%)
Due to their lack of knowledge of COVID-19, respondents found it difficult to answer patients’
questions and reassure them about their care and
likely outcomes. Patients ‘feared the unknown’
and had anxiety around the lack of COVID-19
knowledge. Given a lack of knowledge of how
COVID-19 may impact on patients psychologically,
respondents were reacting to this on an ad hoc
basis.
“Because it was so new for us too, sometimes it
was difficult to answer their questions.” (ID13)
“Lack of knowledge of the disease meant that we
were unable to reassure patients about their care
and how they were improving.” (ID161)
“Patients were very anxious about Covid-19 as so
much [is] still unknown.” (ID204)
Lack of personnel, skill
mix, catering,
housekeeping or dietetic
support (24%)
Due to the COVID-19 risk and some PPE scarcity,
some respondents reported that psychology reviews were delayed or not undertaken, and chaplaincy/ religious persons were unavailable, even in
end of life scenarios. General staff also had a lack
of experience and expertise for identifying and
supporting patients with psychological problems.
“As no one could come onto the wards we were
unable to get a priest or Imam to come and give
religious support.” (ID37)
“Lack of experience and expertise in general staff
for identifying psychological problems and
helping patients deal with emotional
consequences of illness.” (ID4)
Dignity and
respect (27%)
a
Highest sub-category = sub-category for which the highest percentage of participants selected the barrier
Strengths and limitations
A key strength of this study is that it is the first to focus
on fundamental nursing care in the context of SARSCoV-2. Despite the relationship between fundamental
nursing care, patient experience, treatment outcomes
and costs, investigation into fundamental nursing care in
the heavily compromised environment of SARS-CoV-2
is not an objective of current SARS-CoV-2 research programmes. Prior to this study we lacked knowledge as to
the specific impact of the SARS-CoV-2 virus on meeting
patients’ fundamental physical, relational and psychosocial needs.
A further strength is our use of a mixed methods explanatory design. By collecting and integrating quantitative and qualitative data, we have produced a more
comprehensive, in-depth and insightful portrait of the
issues under investigation [35, 36, 47, 48]. To enhance
the usefulness of our results for informing a future nursing protocol, we have used our qualitative findings to explain, illustrate and contextualise our quantitative
findings, with a pragmatic focus on understanding the
key issues which our nursing protocol needs to address
[36–38]. However, it is possible that full, independent
thematic analysis of the qualitative data may have
highlighted different aspects of the data and presented
the data in a different light.
A potential limitation of this study is the absence of a
predefined sample size. We employed a convenience
sampling frame with a sample size determined by the
period of time the survey was open for, which was in
turn constrained by the rapid nature of the wider
COVID-NURSE trial and the need to gather pandemic
Sugg et al. BMC Nursing
(2021) 20:215
evidence as quickly as possible in a rapidly evolving situation. We also experienced respondent fatigue whereby
the number of respondents providing data generally reduced as they worked through the survey items [49].
However, we were not seeking to generalise our findings
beyond the sampled population via inferential statistical
methods which would have formed the basis of any sample size calculation [50]. Furthermore, in all qualitative
items we did reach data saturation, at which point data
from additional respondents was no longer providing
additional clarity or insight; thus, our sample size could
be considered adequate as well as appropriate (as our
eligibility criteria ensured respondents were experts in
the area of interest) [51, 52].
It may have been beneficial to include Allied Health
Professionals (AHPs) within our sample; however, time
constraints and timelines for additional ethical approvals
were prohibitive. The inclusion of AHPs may have provided additional insights, particularly in relation to our
finding that a lack of presence from AHPs was considered a barrier to fundamental care by respondents. In
addition, given the proportions of different staff completing the survey, our results largely represent the views
of registered nurses rather than non-registered members
of the nursing workforce who may have held differing
Implications and future research
Whilst our findings concur with non-empirical reports
from previous pandemics [22–24], to our knowledge this
study is the first to quantify nurses’ own views as to the
impact of a highly infectious virus on their work, and to
combine this with qualitative insights to help explain
why specific elements of fundamental care are affected.
As such, it provides clear guidance for educators, clinicians, managers and policy makers on what to expect
and prepare for in caring for patients in pandemic
situations.
Further research should build on these findings, addressing the following remaining questions: what is the
impact of nurses’ self-reports of missed fundamental
care on missed fundamental care as experienced by patients?; what are the implications on patient safety issues
such as reduced mobility, infection, and malnutrition,
which are often related to missed fundamental care?;
what strategies can be incorporated in nursing care to
reduce the frequency and impact of missed fundamental
care? In our case, we have used these findings together
with further information from our systematic review,
and from nurses and patients themselves on strategies to
confront the barriers to fundamental care identified in
this study, to devise a guideline and nursing protocol for
pandemic situations. We are currently testing this protocol in a cluster randomised controlled trial [33].
Page 15 of 17
Although our data were collected from a specific nursing context – inpatient care for patients with the SARSCoV-2 virus who were not invasively ventilated – we
suggest that our results have the potential for generalising to other care environments and other pandemic
situations globally. Most of the concerns and barriers
identified by our respondents are not specific to the
SARS-COV-2 virus, nor their particular nursing environment. Communication is at the heart of all good nursing
care globally, as it establishes the platform for compassionate and collaborative transactional care which addresses patients’ physical and psychosocial needs [8, 9].
Intrinsic too is the organisation of care and interprofessional working, as well as nursing education about
the epidemiology of illnesses and on specific techniques
to be used. All these areas are not exclusive to the
current SARS-CoV-2 pandemic and we suggest, therefore, that our results will be useful for others devising
strategies to support nursing care in other environments
(such as care homes), other countries and for other
pandemics.
Conclusions
In a survey of nurses caring for patients in hospital with
the SARS-COV-2 virus not invasively ventilated, the majority of respondents rated their ability to meet the needs
of these patients as worse than for patients they normally care for in five of 15 specific fundamental care
areas. These areas included one physical, three relational
and one psychosocial nursing care area, highlighting that
communication with patients and their significant others
was the major and consistent concern for nurses, alongside organising care (especially mobilisation) for patients
nursed in isolation, and addressing patients’ emotional
wellbeing and mental health. The major barriers to fundamental care were the wearing of PPE, the severity of
these patients’ conditions, lack of time, difficulties taking
items and equipment in and out of isolation rooms, lack
of interdisciplinary input, lack of knowledge about
SARS-CoV-2, and fears of catching the illness itself. The
difficulties faced by nurses in establishing relationships
with patients led to concerns that care became merely
functional and not individualised or patient-centred.
These concerns are unlikely to be specific to the SARSCoV-2 pandemic nor the hospital environments represented by our survey respondents. These results should,
therefore, be incorporated into subsequent global pandemic planning by nursing leaders.
Abbreviations
ARC: Applied Research Collaboration; AHP: Allied Health Professionals;
COVID-19: Coronavirus disease 2019; CPAP: Continuous Positive Airway
Pressure; DNAR: Do Not Attempt Resuscitation; ICON: Impact of COVID-19 on
the Nursing and midwifery workforce; MRC: Medical Research Council;
NIHR: National Institute of Health Research; NHS: National Health Service;
PenARC: Applied Research Collaboration South West Peninsula; PPE: Personal
Sugg et al. BMC Nursing
(2021) 20:215
Protective Equipment; PPI: Patient and Public Involvement; RCN: Royal
College of Nursing; SARS-COV-2: Severe acute respiratory syndrome
coronavirus 2; STROBE: Strengthening The Reporting of OBservational studies
in Epidemiology; UKCRC: United Kingdom Clinical Research Collaboration
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12912-021-00746-5.
Additional file 1. Number of respondents providing data per survey
item/ selecting each option within each survey item.
Additional file 2. Completed STROBE 2007 (v4) Statement—Checklist of
items that should be included in reports of cross-sectional studies.
Acknowledgements
We thank the respondents in this study and the other members of the
COVID-NURSE team for their support: Joanne Cooper; Claire Hulme; Nigel
Reed; G. J Melendez-Torres; Harry Tripp; Stephen Wootton.
Authors’ contributions
DAR designed the study as chief investigator of the COVID-NURSE trial, with
input from co-investigators HVRS, A-MRu, HI-S, EC, JTC, SC, FD, PL, AMRa, SS,
MS and ST. A-MRu and DAR designed the survey with input from SB, HH, ST
and RW; HVRS, DAR and HH obtained ethical and governance approvals with
support from MK. HVRS, LM and NM completed quantitative data analysis
with support from MK and HH; HVRS, A-MRu, HI-S and NM completed qualitative data analysis with support from MK and HH. HVRS, DAR, A-MRu and
LM drafted the manuscript. All other authors reviewed the manuscript and
manuscript.
Funding
This work is supported by the NIHR and UK Research and Innovation,
the University of Exeter, ref.: 1920/ Research Ethics and Governance Office,
Lafrowda House, St Germans Road, Exeter, Devon, EX4 6TL. The work is also
supported by the NIHR Applied Research Collaboration South West
Peninsula. The views expressed in this publication are those of the authors
and not necessarily those of the National Institute for Health Research or the
Department of Health and Social Care. The sponsor and funding sources
have had no role in the design of this study, nor during the collection,
analysis, and interpretation of data, nor in writing this manuscript.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was granted ethical approval by the University of Exeter Medical
School Ethics Committee (Application Number Jul20/D/256) and Health
Research Authority research and development governance assurance (IRAS
reference 287288). Informed consent to participate in the study was
obtained electronically from participants at the beginning of the survey. All
methods were performed in accordance with the relevant guidelines and
regulations including the Declaration of Helsinki.
Consent for publication
Informed consent to publish anonymised participant data was obtained
electronically from participants at the beginning of the survey.
Competing interests
AMRa is President of the Royal College of Nursing. All other authors declare
that they have no competing interests.
Author details
1
College of Medicine and Health, University of Exeter, St Luke’s Campus,
Heavitree Road, Exeter EX1 2LU, UK. 2School of Health and Society, University
Page 16 of 17
of Salford, Allerton Building, Frederick Rd, Salford M6 6PU, UK. 3Northern Care
Alliance NHS Group, Stott Lane, Salford M6 8HD, UK. 4Department of Health
and Caring Sciences, Western Norway University of Applied Sciences,
Inndalsveien 28, 5063 Bergen, Norway. 5The National Institute for Health
Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula
(PenARC), Exeter, UK. 6The Royal Marsden NHS Foundation Trust, Fulham
Road, London SW3 6JJ, UK. 7School of Medicine, University of Nottingham,
Queens Medical Centre, Nottingham NG7 2UH, UK. 8Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK.
9
NIHR Exeter Clinical Research Facility, Royal Devon and Exeter NHS
Foundation Trust, Barrack Road, Exeter EX2 5DW, UK. 10Institute of Biomedical
and Clinical Science, College of Medicine and Health, University of Exeter, St
Luke’s Campus, Heavitree Road, Exeter EX1 2LU, UK. 11Department of
Respiratory Science, University of Leicester, University Road, Leicester LE1
7RH, UK. 12University Hospitals of Leicester NHS Trust, Biomedical Research
Centre – Respiratory, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
Received: 18 December 2020 Accepted: 8 October 2021
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1
Lab Week 3
Chamberlain University College of Nursing
Course Number: Course Name
Name of Instructor
Assignment Due Date
2
1. Part One Step 1 For our first broad-based search, choose exactly one of the 12
articles listed that interests you. Use the underlined words in your chosen article
to search and see how many articles from the Pro-Quest Nursing database contain
these underlined words. If the Pro-Quest Nursing database is no longer available
through the Chamberlain Library web site, then please do this instead: “Search
Entire Chamberlain Collection.” In the gray / grey box below, please clearly
indicate which of the 12 allowed articles that you have selected for this part of the
assignment.
Please disregard this question here based on the new Instructions / Directions.
Please feel very free to type up your brief article summary here. Thanks much !!
3
2. Part One Step 6 Place a screenshot of your search results ( topic and the number
of articles containing your search terms ) in the gray / grey box below.
Please disregard this question here based on the new Instructions / Directions.
4
inside this gray / grey box.
A. On your search, what terms did you use?
Please disregard this question here based on the new Instructions /
Directions.
B. On your search, what other things did you mark on the search page before
Please disregard this question here based on the new Instructions /
Directions.
C. On your search, why did you choose the key words that you did?
Please disregard this question here based on the new Instructions /
Directions.
D. On your search, how many articles were found with these search terms ( you find
this answer on your screen shot submitted on the page just previous here ) ?
Please disregard this question here based on the new Instructions /
Directions.
5
4. Part Two Step 1 For our second more narrow search, go back and search using
the entire title of the article you used the key words from in your first search.
Paste the entire title into the search bar and find the full article ( do not checkmark
anything to narrow your search this time! ). Find a full text pdf of your chosen
article. If you have difficulty finding a full text pdf of your chosen article, please
see Files along the left of the computer screen in the Math 225 course shell /
template, and then click on Week 3 Files. Click the folder for the Week 3 lab and
you should be able to find the needed full text pdf. In the gray / grey box below,
using the APA Style Manual seventh edition. What you type into the box below
will also be an entry in your References list on the last page of this document.
Please disregard this question here based on the new Instructions / Directions.
6
5. Part Two Step 3 In your one specific chosen article, please find ONE frequency
table and / or ONE graph within the article and place a screenshot of the table and
/ or graph in the gray / grey box below. Thank you !!
7
graph.
A. What type of study is used in the article ( quantitative or qualitative or both ) ?
8
graph.
B. What type of table and / or graph did you choose for your lab assignment? What
characteristics or clues or indicators make it this type?
9
graph.
C. Describe the data displayed in your chosen table and / or graph. Potentially
consider class size, class width, total frequency, list of frequencies, class
consistency, and other elements or factors. Depending on the table and / or graph
that you chose, many of the things in the list above might not apply, and that is
OK ! With this question, do the best that you can, given what you have to work
with. Thank you !!
10
graph.
D. Draw a ( tentative and provisional ) conclusion about the data from the table and
/ or graph that you chose.
11
graph.
E. How else might these data have been displayed ( OTHER THAN using the table
and / or graph that you have been using in this assignment ! ) ? Please carefully
discuss PROS and CONS of TWO OTHER presentation options, such as a
different table or a different graphical display option choice. Please look
especially careful at the grading rubric row for this question. Class members
in the past have struggled a lot with this question. Thanks !!
12
graph.
F. Please give the full APA Style Manual seventh edition reference of the specific
chosen article that you are using for this lab assignment. This is simply a repeat
of the answer you gave in Question 4. further above in this assignment document.
13
References
Type your references here using hanging indent and double line spacing (under
“Paragraph” on the Home toolbar ribbon). See your APA Manual ( seventh edition ) and
the resources in the APA section of Resources for reference formatting.

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