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

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 SARS-CoV-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 whom they cared. Additionally, they worried about their 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 Post-Traumatic 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].

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 SARS-CoV-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.

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.

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.

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’ non-empirical 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.

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 SARS-CoV-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.