Nurses’ strategies for overcoming barriers to fundamental nursing care in patients with COVID‐19 caused by infection with the SARS‐COV‐2 virus: Results from the ‘COVID‐NURSE’ survey

Abstract Aims To identify strategies used by registered nurses and non‐registered nursing care staff in overcoming barriers when providing fundamental nursing care for non‐invasively ventilated inpatients with COVID‐19. Design Online survey with open‐ended questions to collect qualitative data. Methods In August 2020, we asked UK‐based nursing staff to describe any strategies they employed to overcome barriers to delivering care in 15 fundamental nursing care categories when providing care to non‐invasively ventilated patients with COVID‐19. We analysed data using Framework Analysis. Results A total of 1062 nurses consented to participate in our survey. We derived four themes. 1) Communication behaviours included adapting verbal and non‐verbal communication with patients, using information technology to enable patients’ significant others to communicate with staff and patients, and establishing clear information‐sharing methods with other staff. 2) Organizing care required clustering interventions, carefully managing supplies, encouraging patient self‐care and using ‘runners’ and interdisciplinary input. 3) Addressing patients’ well‐being and values required spending time with patients, acting in loco familiae, providing access to psychological and spiritual support, obtaining information about patients’ wishes early on and providing privacy and comforting/meaningful items. 4) Management and leadership behaviours included training, timely provision of pandemic information, psychological support, team huddles and facilitating regular breaks. Conclusions Our respondents identified multiple strategies in four main areas of clinical practice. Management and leadership are crucial to both fundamental care delivery and the well‐being of nurses during pandemics. Grouping strategies into these areas of action may assist nurses and leaders to prepare for pandemic nursing. Impact As these strategies are unlikely to be exclusive to the COVID‐19 pandemic, their global dissemination may improve patient experience and help nurses deliver fundamental care when planning pandemic nursing. However, their effectiveness is unknown. Therefore, we are currently evaluating these strategies in a cluster randomized controlled trial.


| INTRODUC TI ON
The challenges of the SARS-COV-2 viral pandemic and the disease it causes  have led to an increase in missed nursing care or 'care left undone', defined as any aspect of nursing care that is omitted or delayed, in part or in whole (Kalisch et al., 2009). In our survey of 1062 UK nursing staff caring for inpatients with COVID-19, respondents rated their ability to meet patients' needs in many fundamental areas of nursing care as worse for hospitalized patients with COVID-19 than for other patients , acknowledging that care for these patients was being missed more frequently than in other clinical situations. In a parallel systematic review of 64 articles on fundamental nursing care in five pandemics, we synthesized reports on nursing strategies used to address barriers to care , but found that the literature was mostly non-empirical, of poor quality and provided little robust guidance to nurses. To design and test a fundamental care nursing protocol for non-invasively ventilated inpatients with COVID-19 , we also asked nurses experienced in caring for these patients what they did to reduce the potential for missed care. We report that data here.

| BACKG ROU N D
Patient experience of care is associated with safety, clinical effectiveness, care quality, treatment outcomes, costs and service use (Black et al., 2014;Darzi, 2008;Doyle et al., 2013). Nursing care is a key determinant of this experience (Graham et al., 2018, Murrells et al., 2013. Patient safety failures are correlated with a high prevalence of missed nursing care Aiken et al., 2017;Ausserhofer et al., 2014;Kalisch, 2006;Kalisch et al., 2009). The extent of missed care is related to poor patient outcomes, increased mortality and adverse events and poor patient satisfaction and experience Bruyneel et al., 2015;Kalisch et al., 2014;Recio-Saucedo et al., 2018).
Both nurses and patients have indicated that important elements of care are regularly missed, including nutrition, hygiene (e.g. bathing; mouth care), ambulation/supporting mobility, communication/ talking with patients and emotional and psychological support (Ball et al., 2016;Griffiths et al., 2018;Kalisch, 2006;Kalisch et al., 2014).
These elements are regarded as 'fundamental' care: 'actions on the part of the nurse that respect and focus on a person's essential needs to ensure their physical and psychosocial wellbeing ' (Feo et al., 2018' (Feo et al., , p. 2292. These needs are met by developing a positive and trusting relationship with the patient and their family/carers; thus, these actions include nurses' relational as well as transactional behaviours (Feo et al., 2018;International Learning Collaborative, 2019).
We undertook our survey in the early phase of the pandemic in the UK during a time that information and understanding of the virus were lacking and vaccines were not available .
Healthcare services were disrupted by very large numbers of patients admitted who were being cared for by nurses and other care had no role in the design of this study; nor during the collection, analysis and interpretation of data and nor in writing this manuscript or in the decision to submit the manuscript for publication. others to communicate with staff and patients, and establishing clear informationsharing methods with other staff. 2) Organizing care required clustering interventions, carefully managing supplies, encouraging patient self-care and using 'runners' and interdisciplinary input. 3) Addressing patients' well-being and values required spending time with patients, acting in loco familiae, providing access to psychological and spiritual support, obtaining information about patients' wishes early on and providing privacy and comforting/meaningful items. 4) Management and leadership behaviours included training, timely provision of pandemic information, psychological support, team huddles and facilitating regular breaks.

Conclusions:
Our respondents identified multiple strategies in four main areas of clinical practice. Management and leadership are crucial to both fundamental care delivery and the well-being of nurses during pandemics. Grouping strategies into these areas of action may assist nurses and leaders to prepare for pandemic nursing.
Impact: As these strategies are unlikely to be exclusive to the COVID-19 pandemic, their global dissemination may improve patient experience and help nurses deliver fundamental care when planning pandemic nursing. However, their effectiveness is unknown. Therefore, we are currently evaluating these strategies in a cluster randomized controlled trial.
The majority of our respondents rated care as worse for COVID-19 patients than others they cared for in specific areas of mobility, talking and listening, non-verbal communication, communicating with relatives, carers and significant others and caring for patient's emotional well-being, anxiety and depression. In all other areas of care, around one-third of respondents indicated that care was also worse for these patients .
Our respondents identified specific barriers to meeting patients' fundamental care needs. Foremost was infection control, specifically nursing patients in isolation and wearing personal protective equipment. Insufficient stock, and staffs' inability to take items in and out of isolation rooms without donning and doffing personal protective equipment, also impeded physical care. Another significant barrier 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 the staffs' own reluctance to spend time with patients for fear of catching COVID-19. This was compounded by a lack of knowledge about COVID-19 which impeded respondents' ability to answer patients' questions. Throughout their accounts, respondents also highlighted the impact of restrictions on visitors for both patients and nursing staff .
Inpatients with COVID-19 have also reported experiencing poor communication, a lack of support and assistance, insufficient information and/or equipment (Healthwatch, 2020) together with a range of negative emotions and psychological consequences due to a lack of social interaction, limited mobility, difficulties communicating with staff and a lack of information about their illness and treatment (Shaban et al., 2020). In addition, patients' relatives, carers and significant others have reported poor communication from staff and may not be kept well informed about the patient (Healthwatch, 2020).
These reports mirror findings from our own systematic review on fundamental nursing care in pandemic situations, where we identified wearing personal protective equipment, adequate staffing, infection control procedures and emotional challenges as barriers to care . Our review demonstrated the poor quality of research on pandemic nursing practice with only 19 empirical articles in 64 included papers covering five pandemics. Despite the substantial barriers to care identified, at the time of undertaking this review and our survey, there were no evidence-based guidelines for nursing patients infected with the SAR-COV-2 virus who are not invasively ventilated (i.e. may be receiving no ventilation or ventilatory support without tracheal intubation), who represent the majority of hospitalized patients under this condition (Torjesen, 2021).
Consequently, we designed the COVID-NURSE fundamental nursing care clinical protocol for patients hospitalized with COVID-19 not invasively ventilated for evaluation in a cluster randomized controlled trial  using data from i) a survey of nurses' experiences of caring for patients with COVID-19, including the barriers encountered in delivering fundamental care (reported elsewhere, Sugg et al., 2021) and strategies adopted to overcome these (reported here); ii) a systematic review ; and iii) co-creation workshops involving patients with experience of hospitalization with COVID-19 and nurses caring for them.
In this paper, we report our survey data on strategies used by nurses to overcome barriers to care. We describe our study using both cross-sectional (STROBE) (Knottnerus & Tugwell, 2008) and qualitative (COREQ) (Tong et al., 2007) study reporting guidelines.

| Aim
To identify strategies used by registered nurses and non-registered nursing care staff in overcoming barriers when providing fundamental nursing care for non-invasively ventilated inpatients with COVID-19.

| Design
We undertook a qualitative study with data collected using openended survey questions and analysed using a Framework approach (Ritchie et al., 2013).

| Setting
We collected data for the study in the UK using Qualtrics™ online survey software (Qualtrics, 2020).

| Participants
Eligible respondents were UK-based registered nurses and nonregistered auxiliary nursing/healthcare support workers/assistants working in geographically diverse general or specialist hospitals, who had the experience of nursing non-invasively ventilated inpatients with COVID-19. Respondents who had only nursed invasively ventilated patients were ineligible.  Table 1). In each subsection, we asked respondents to provide free text describing what, if any, strategies they employed to try and overcome barriers to that sub-category of care.

| Survey instrument
We also collected demographic information ( Table 2). In developing the survey, we sought advice from members of our patient and public involvement group, our patient and public involvement coinvestigator, the COVID-NURSE trial co-investigators and members of the wider research team. We piloted the survey with four nursing teams and amended it according to their feedback.

| Data collection
We ran the survey from the 3rd to 26th August 2020. As our study was undertaken rapidly to provide information to guide our 'COVID-NURSE'  intervention development, our sample size was not predetermined, seeking to recruit as many respondents as possible during the survey timeframe.
We invited a convenience sample of respondents by circulating the survey link to a database of nurses who had consented to be approached for COVID-19-related research studies through the 'Impact of COVID-19 on the Nursing and midwifery workforce' We sent a survey link to nurses on our database and to key gatekeepers in the networks listed above. We asked gatekeepers to circulate the link via newsletters, 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 TA B L E 1 Survey structure: Fundamental care areas and subcategories of care

| Ethics considerations
We were granted ethics approval by the University Ethics Committee (Application Number Jul20/D/256) and the United Kingdom Health Research Authority research and development governance assurance (IRAS reference 287288). At the beginning of the survey, respondents electronically gave their informed consent to participate, which included consent to publish anonymized respondent data.

| Data analysis
The UK Clinical Research Collaboration (UKCRC)-registered University of Exeter Clinical Trials Unit received, cleaned and processed the data. Study researchers uploaded anonymized data sets to Microsoft Excel (Microsoft Coproration, 2013). We applied pairwise deletion to each survey item to account for missing data and maximize the data available for analysis. For demographic variables, we calculated percentages from the number of respondents who provided data for that specific variable. We combined ethnicity data into standard categories (Office for National Statistics, 2019).
We analysed data using Framework Analysis (Ritchie et al., 2013) to allow for both inductive and deductive approaches in combining our study aims/survey questions with respondents' original accounts (Pope & Mays, 2006;Ritchie et al., 2013).
We achieved familiarization with the data through reading responses and then completed the first cycle of coding of responses, developing an initial thematic framework as we analysed batches of surveys (Miles et al., 2014). Using this framework, we completed second cycle coding and analysed responses thematically using a constant comparison approach, examining similarities and differences to categorize the strategies described in our framework (Miles et al., 2014;Thorne, 2000).
We organized survey responses by sub-category of care (Table 1).
We analysed all responses (regardless of sub-category of care) together rather than analysing each sub-category independently; however, we maintained a record of which sub-category they related to in order to inform our interpretation of the data and understanding of context and meaning. We thus charted data in an analytic/framework matrix to allow analysis in each theme, as well as across each sub-category of care, and the further refinement of themes (

| Validity and reliability/rigour
We were a multidisciplinary team consisting of four researchers (HH, DR, AMRu, HS) of mixed gender with backgrounds in nursing (2), nursing education (2), mental health services research (2) and clinical research (3). All researchers have PhDs, were trained and experienced in qualitative data analysis and were employed as a research fellow (HH), Lecturer (HS), Senior Lecturer (AMRu) or Professor (DR) at the time of the study. AMRu independently coded a subset of the raw data which HS double-coded and verified, and the research team discussed the development of themes until consensus could be achieved, supporting the credibility and reliability of data interpretation (Barbour, 2001;Ritchie et al., 2013). Thus, the rigour of our approach and validity of our analysis were enhanced through the consideration of multiple differing perspectives in our research team (Barbour, 2001;Houghton et al., 2013;Ritchie et al., 2013) alongside our researchers' expertise and skills in the methods used (Yardley, 2017).

| Patient and public involvement
When designing the survey and all other aspects of the project, we were advised by a Patient Advisory Group consisting of eight people who had experience of being cared for in hospital with COVID-19 or were a relative of someone who had been admitted.

| FINDING S
A total of 1062 eligible respondents consented to provide survey data; 84 of these provided no further data. Respondent characteristics are summarized in Table 2.
The number of respondents specifically providing narrative data on strategies for each sub-category of care ranged from 46 to 318 (Table 3).
The strategies described by respondents were understood in four themes as follows: (1) Communication behaviours, (2) Organization of care, (3) Addressing patients' well-being and values, Respondents described the importance of explaining to patients that they were grouping activities, and why, to help encourage patients to ensure that all of their own needs had been met. Respondents also noted one danger associated with this approach, in that patients saw staff less regularly: This did increase the overall care of the patient but also meant there was reduced overall contact.
Thus, this needs to be balanced with strategies to meet patients' psychosocial needs and circumvent their social isolation.

| Managing supplies
Connected to clustering interventions was managing supplies to ensure that staff took everything they needed into a patient's room: [You] made sure that if you were going inside a patient's room and about to put on personal protective equipment, that you had everything beforehand.
Some respondents 'developed a system' (ID16) or 'created a planned checklist' (ID33) to assist with this and ensured that supplies were kept in accessible places either inside or outside patients' rooms: We created trolleys outside rooms with supplies on, e.g. wipes, bags, linen etc…to prompt people to take everything in. (ID558) Respondents also reported using broader stock management strategies, including regular re-stocking checks and ensuring sufficient supplies to items and equipment, such as hoists and commodes, were regularly ordered and made available:

| Theme 3: Addressing patients' wellbeing and values
Respondents described strategies to maintain and respect patients' views, dignity and well-being, including supporting mental health

| Providing privacy, comfort and meaning
To maintain patients' privacy and dignity, respondents created makeshift barriers during personal care such as 'a pillowcase on a drip stand to cover the window whilst I checked the patient's skin' (ID272) and 'if we could not find any screens, then we would try and hang bed sheets up' (ID377).
Respondents also described providing patients with meaningful and comforting items, particularly given visitor restrictions and patients' isolation. These included food, clothes, personal items and often related to the patient's culture and spirituality, such as an 'electronic Bible and Koran to play passages' (ID533). Respondents encouraged family members to drop off such items (ID334), or staff themselves provided them: Wherever possible [I] did some shopping for the patients to get items they wanted (ID334) One key purpose of providing patients with items was to 'occupy the patient's time' during isolation (ID373), 'providing things for them to do once they felt well enough' (ID340) such as reading materials, activity books and playing cards. Respondents also provided patients with comfort by creating 'all about me boards' (ID533) comprised of photos and messages provided by significant others:

| Theme 4: Management and leadership
To enable staff to use the strategies described, feel equipped to meet patients' needs and maintain their own well-being while doing so, respondents highlighted the importance of management and leadership strategies including education and information provision (constituent theme a) and supporting staff (constituent theme b).
These strategies were considered useful in the context of staffs' lack of knowledge about COVID-19, fear of catching COVID-19 and lack of expertise coupled with reduced presence from specialist services.

| Education and information provision
Respondents described needing training and upskilling in areas including information technology, non-verbal communication, mobilizing patients, palliative care, escalation pathways, spiritual beliefs and practices and personal protective equipment. Respondents reported that regular team briefs/huddles were important in providing staff with information, "regular reassurance" (ID626) and a supportive space to "share experiences and concerns" (ID481), "answer questions" (ID564), and share information about how best to support patients. Nurse leaders also sought to provide staff with space away from the ward and ensure they took regular breaks: The utilisation of safety huddles and ward safety briefings to identify patients at risk and needs that were required by specific patients. Our results make a substantial contribution to the disappointingly scant existing empirical literature on fundamental nursing care in a pandemic, reviewed in . Of the 12 previous qualitative studies in this area, most are very small and report nurses' experiences of care, not their adaptive strategies. Unlike our study, in previous studies, any suggestions for care strategies are mostly author generated, rather than being based on nurse data directly (e.g. Corley et al., 2010;Kang et al., 2018;Shih et al., 2007).
Our study is the largest to date that has sought data directly from nurses on strategies to adapt their care. Our study is also the first in this area that explicitly uses the Fundamentals of Care framework (Kitson et al., 2010) to structure data collection and analysis.
For the same reasons as above, our data also confirm the litera-

| Limitations
One limitation of this study is our convenience sampling frame, with a sample size determined by the period of time the survey was open, which was in turn constrained by the need to gather information quickly to design our 'COVID-NURSE' intervention . We also potentially experienced respondent fatigue, whereby the number of respondents providing data generally reduced towards the end of the survey, although we do not know if the small number of narrative responses to individual items is a product of fatigue or that respondents genuinely did not have any strategies to contribute (Lavrakas, 2008). However, in all items/each sub-category of fundamental care we did reach data saturation, at which point data from additional respondents were no longer providing additional clarity or insight; thus, our sample size in and across each sub-category of care could be considered adequate as well as appropriate as our eligibility criteria ensured respondents were experts in the area of interest (Morse, 1995;Morse, 2015).  Kitson et al., 2010). Many of the strategies identified by our respondents may help to address the negative experiences reported by patients and significant others, including improving communication with staff, providing an increased level of information, ensuring sufficient equipment is available, improving patients' mobility, supporting patients' well-being in the face of decreased social interaction and keeping significant others up to date (Healthwatch, 2020;Shaban et al., 2020).
In particular, we draw attention to the need for management and leadership. It is here where nursing, particularly fundamental care nursing, has much to gain. Leadership on the ground is required to ensure nurses are trained, upskilled and up to date by the timely provision of pandemic information. Good leaders provide psychological support, for example using team huddles and ensuring that nurses' needs for breaks and self-care are identified and acted on. However, although not an element of our thematic analyses, nurses can learn from the pandemic experiences of others (Shih et al., 2007) in using the disruptive potential of the COVID-19 pandemic to advance the value of nursing, particularly those fundamental care behaviours included in the FoC model (Feo et al., 2018, Kitson et al., 2010, by engaging forcefully and visibly with political, policy and media actors. Although our data were collected from a specific nursing context-inpatient care for patients with COVID-19 who were not invasively ventilated-these strategies are unlikely to be specific to the COVID-19 pandemic or the hospital environment represented by our respondents. They may, therefore, inform planners devising strategies to deliver nursing care in other environments (such as care homes), other countries and for other pandemics globally.
Unfortunately, there is currently extremely limited evidence on the effectiveness of any of the identified strategies. Few studies focus on patient experience or outcomes. Although many COVID-19 resources now exist, for example staff well-being (The Kings Fund, 2021), infection control (Gould & Purssell, 2021) and oxygen management (Messer et al., 2021), fundamental nursing care has not been the focus of guidelines . To prepare for the continuation of the COVID-19 pandemic and future pandemics, the effectiveness of these strategies for meeting patients' fundamental care must be evaluated.
This research need will enable evidence-based care to be provided in future and provide guidance for educators, clinicians, managers, leaders and policymakers on potentially useful strategies for meeting patients' fundamental care needs in pandemics and other situations where patients are nursed in isolation. Now that we have a large amount of observational data driven by the FoC model, experimental research is our research community's next step (Richards, 2020).
Consequently, we have incorporated these strategies into a fundamental nursing care clinical protocol that we are currently evaluating in a cluster randomized controlled trial . This should be only the first step in rigorously testing the FoC model in multiple different settings, cultures and contexts.

ACK N OWLED G EM ENTS
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 and Stephen Wootton.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15261.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared due to the sensitivity of qualitative