MINI STRY OF EDUCATION MINISTRY OF HE ALTH AND TRAINING HANOI MEDICAL UNIVERSITY JI — — PHAM THI DUNG PERCEPTION AND BARRIERS OF INTENSIVE CARE UNIT NURSES IN COMPREHENSIVE CARE DURING COVID-19 PANDEMIC IN HANOI MEDICAL UNIVERSITY’ HOSPITAL VIETNAM GRADUATION THESIS BACHELOR OF SCIENCE IN NURSING Advanced Program in Nursing 2016-2021 Supervisor: Assoc Prof Hoang Bui Hai M.D Ph.D Mai Till Hue MPH Hanoi 2021 r-u -ÍM Qỉ ugc V Hl ĩii ACKNOWLEDGEMENT I would like to express my deepest gratitude to my supervisor Assoc Prof Hoang Bui Hai M.D P11.D arid Mrs Mai Till Hue MPH for the excellent guidance, caring, patience and providing with the tremendous support during this research I am also grateful to all lecturers in the Institute of Intensive care and Emergency department Hanoi Medical University for their comments, helps and supports I would like to express my sincere thanks to all hospital staff in Intensive Care Unit at Hanoi Medical University Hospital for their facilitation in data collection process I place on my record, my sincere gratitude to all members in the research team for sliaring expertise, valuable support and encouragement extended to me Hanoi May 5th 2021 Thesis author Plain Thi Dung r-u -ÍM Qỉ ugc V Hl ỉv DECLARATION I hereby declare that this thesis is composed by myself, which lias not been previously submitted, either in a part or in full, for a degree to any other institution or university As far as I know, material lias been previously published or written by other persons are not contained in my thesis except where reference has been shown in the text Hanoi May 5* 2021 Thesis author Pham Till Dung CONTENTS 3.32 The expected factors that should be available to achieve RECOMMENDATION 59 REFERENCES APPENDIX LIST OF TABLES LIST OF FIGURES Figure 2.1 The process of Qualitative data collection 17 Figure 2 The Qualitative research process 19 LIST OF ABBREVIATIONS COVID-19 HCWs Coronavirus disease 2019 Health-care workers ICU Intensive care unit HMƯH WHO Hanoi Medical University Hospital World Health Organization r-u -ÍM Qỉ ugc V Hl INTRODUCTION Comprehensive patient care is a highly nursing healthcare model which has been widely developed in many parts of the world to meet the increasing demand of patients Its principles are based on the combination of both the clinical treatment and non-treatment aspects which include personal hygiene, daily diets, and mental care [1] While this model of care has been fundamentally well-established in highincome countries such as the United States, tire United Kingdom Australia, and the Netherlands [2] [3], [4], (5) it is quite a vague concept in mam' resources’ constraint countries Particularly, in Vietnam the implementation of comprehensive care has only been constricted to highly standardized, private hospitals; and most public hospitals have been absent or incomplete of this healthcare model In fact, several nursing cares associated to non- treatment aspects have been realized by patient’s relatives In 2013 and 2016 Nutan Potdar et al performed studies in the Intensive care unit (ICU) of Krishna hospital India regarding multiple barriers experienced by nurses and doctors when providing comprehensive care for patients They revealed that increased workload, less equipment and lack of human resources were major barriers for medical staffs [6], [7] The complex (COVID-19) pandemic progression has of of catastrophically the coronavirus been disease a global 2019 health consequently care burden changed Ill to adapt addition to nursing this new care situation lias To accommodate, fluffily practiced the Vietnamese “comprehensive nurses care" in the that ICU consisted have ofa dedicated unacccpting model the assistance for COVID-19 care the patient’s relatives as r-u -ÍM Qỉ ugc V Hl There lias so far liot been any understanding related to the comprehensive care in Vietnam, especially in the ICƯ during the COVID-19 pandemic Thus, we conducted this study with objectives: To describe barriers of nurses in comprehensive care during the COMD19 pandemics in the Intensive Care Cnit at Hanoi Medical University Hospital, I ietnam from October to November 2020 To understand these nurses' perspectives about Hospital, comprehensive Intensive Care care Unitduring at the Medical COIID-19 University pandemics in the Vietnam from October toHanoi November 2020 CHAPTER 1: LITERATURE REVIEW 1.1 Comprehensive care model 1.1.1 Comprehensive care definition Comprehensive care is an advanced healthcare model worldwide that has been widely acknowledged as the best way forward to achieve the integral healthcare demand of multimorbid patients [1Ị [8] [9] [10] [11] [12] In addition, comprehensive care can be defined as active initiatives seeking to structure and coordinate care and improve health outcomes while limiting health care expenditures [1] Many different terms are being applied for comprehensive care consisting of integrated care, care according to guidelines, cases and general care management Moreover, the models are considered comprehensive if they meet several of the health care needs of people with multiple chronic illnesses, functional disabilities, and/or high levels of health care utilization and if the health care senices are provided by numerous HCWs [12] Multiple theories have been proposed to “patient- centred care" as a comprehensive care criterion [ 10] [ 11 ] [ 12] Its principles are based on the combination of both the clinical treatment and non-treatment aspects which include personal hygiene, daily diets, and mental care Titus, comprehensive health care is always considered as an essential part of every health facility as a mean to promote treatment outcomes of patients [ ] 1.12 Comprehensive care and the COVID-19 pandemic -c -ÍM Qỉ ugc V Hl 1.12.1 Overview oftheCOV'ID-19 pandemic According to World Health Organization (WHO), the COVID-19 is an infectious disease caused by a newly discovered coronavirus It lias triggered off a worldwide pandemic of a respiratory illness that was first identified in December 2019 in Wuhan City' in China [13] This novel coronavirus is structurally associated with the virus that causes severe acute respiratory syndrome (SARS) This has also been explored in prior studies that these symptoms of COVTD-19 can range from a mild cold to moderate diseases, even life-threatening In addition, fever, cough, and fatigue are the most common symptoms at the onset of COVID-19 illness while other symptoms include sputum production, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia [14], [15], [16], [17] Moreover, previous studies have emphasized tliat person-to-person transmission is a primary infectious pathway for COVID-19 [17] [IS] The spreading occurs primarily via direct contact or through droplets by coughing or sneezing from an infected individual The critical solution to prevent and slow transmission is to have a proper perception of the COVID-19 virus, the disease it causes, and how it spreads Protect yourself and others from infection bv washing your hands or using alcohol-based detergents frequently and not touching your face as suggested by WHO [19] Additionally, maintaining a distance of at least meter between yourself and others is also the best way to reduce the risk of infection when they cough, sneeze or speak Maintain greater distance between yourself and others when indoors Make wearing a mask normal part of being around other people The appropriate use storage, and cleaning or disposal are essential to make masks as effective as possible On top of that, awith large number recent studies have recognized health is the that ongoing COVID-19 outbreak is theof latest respiratory threat to564 disease global Indeed, and byworldwide March it488 lias affected 2021 there nearly have every been region 115 2S9of 961confirmed the world people; cases confirmed the deaths of more than 000 -c -ÍM Qỉ ugc V Hl cases and 35 deaths have been reported in mainland Vietnam and as known as having clusters of cases of transmission classification [19] Therefore, health- care workers (HCWs) have played a vital role in every country- Their health and safety are crucial not only for continued and safe patient care but also for controlling any outbreaks [20] However, health care providers during a severe COVID-19 outbreak have been under extraordinaty stress and baniets associated with a high risk of infection, stigma, lack of staff, and uncertainty For instance, the following studies were conducted on HCWs’ experiences Front-line medical staff who take care of patients with COVID-19 are at increased risk for mental health problems, such as anxiety, depression, insomnia, and stress [21] Frontline doctors and nurses with no expertise in this infectious disease face additional challenges as they adapt to a completely new work environment in these stressful situations T1ŨS has also been explored in prior studies in 2020 by Yicen Van and his colleagues, insufficient and excessive protection will have adverse effects on the skin and mucous membrane of healthcare workers [22] LU.2 rite situation of comprehensive care before the COV1D-19 pandemic By enhancing the quality and continuity of care, comprehensive care aims improve patient health outcomes, while at the same time creating efficient use of healthcare resources There have been numerous studies to investigate overview of comprehensive care programs performed for patients with multiple chronic diseases indicated that evidence of their effects on patients and caregivers is inconsistent [12] [23], [24], [25] [26] [27] [28] In most of these reviews, the criteria for inclusion in the studies were rather narrow ill multiple countries Studies are considered to be of high quality if they meet five criteria: design's strength (review, meta-analysis, or controlled trials with the equivalent concurrent control groups), adequacy of the sample (representative sufficient -w.- -ÍM QỈ Hgc V Hl number), the validity of measures, reliability of data analysis techniques, and rigor of data analysis Some reviews in general consist of randomized controlled trials [12] [24] [26] while others only evaluated the impact of programs on patient outcomes [12] [26] [27] [28] or included studies showing positive effects of comprehensive care programs that have shown the potential to refine quality, efficacy, or health-related outcomes of care for patients were identified [12] Furthermore, most reviews provide limited information about the content of the comprehensive care program Therefore, relevant information from the nonrandomized trials and information on the impact programs have on caregiver outcomes is barely summarized Besides care in moderate there multiple were countries, inconsistent each results country' of also comprehensive had mixed effectiveness brokered by the In Sax 2015 Institute an “evidence for theof check” Australian rapid Commission review on for Safety the effectiveness regarding lite of best comprehensive available care research in acute evidence settings step-by-step as defined approach By to providing gain insight an iterative, into the systematic, characteristics and programs effectiveness for patients, of these they new emphasized that following the new comprehensive three elements: care systems standard to will support incorporate care: development comprehensive of care comprehensive and quality care in plans; health delivery care In of addition, they the results found 16 were articles, mixed and of which consisted regarding 12 their (75%) effects, were of were moderate of to high methodological quality, three (18.75%) quality and one (6.25%) was of low quality All were relevant for and generalizable to the Australian acute care settings and populations [29] Additionally, little is known about program features that may be relevant to positive outcomes of care and about the groups of patients who may benefit most from comprehensive care For instance, the effectiveness of comprehensive care was comparable or more positive than that of ordinan- care Ulis has also been explored in a prior systematic study in multiple electronic databases for English language papers published between January 1995 and January 2011 by De Brain and his colleagues [1] that tile profitable effects of comprehensive care on inpatient health care utilization Besides, evidence is also found for the positive effects of comprehensive care on patient health behaviour, perceived quality of care, and satisfaction of patients and caregivers Insufficient evidence has been found for the profitable effects of comprehensive care on quality of life related to mental health, outpatient healthcare utilization, medication use and healthcare costs No evidence was found for the profitable effects of comprehensive care on cognitive function, depressive symptoms, functional status, mortality', quality of life on physical function, and caregiver burden -w.- -ÍM QỈ Hgc V Hl 1 Despite the fact tliat several (good quality) studies have been performed over the years to estimate the value of comprehensive care for multimodal and/or frail patients, there is insufficient evidence for the efficacy of which More goodquality studies and/or studies that enable meta-analysis are needed to determine which particular taiget groups will benefit from comprehensive care Furthermore, evaluation studies can be improved by utilizing more appropri ate outcome measures, for example, measures related to care goals defined by patients (individuals) However, this information is critical because of growing interest in what will help the best care for patients with multimorbidity especially in the ICU which supports and improves patients* health with multimodal and/or frail A number of questions regarding the effectiveness of comprehensive care in ICU remain to be addressed Rarely public research in Illis area is performed not only in Vietnam but also in over the world Instead of that, it was developing knowledge in specific units such as the endocrinology unit [2], mental health unit [3] gerontology unit [12] [23] et Unfortunately, these mentioned studies are not available for Vietnam Therefore, evaluating and improving the quality of care and the urgency of implementing a new comprehensive model at ICU in Vietnam is a difficult challenge 1.12.3 The situation of comprehensive care during the cot ID-19 pandemic The COVID-19 was declared with a rapid global outbreak Unfortunately, a large proportion of infected patients need admission and comprehensive management, however, the knowledge about the effectiveness of comprehensive care as well as barriers of medical staff accomplishing this model on those patients have been generally limited, especially in ICU While it is clear tliat incomprehensive cate could weaken treatment efforts in every health facility, this issue is far worse in the ICU including in Vietnam -w.- -ÍM QỈ Hgc V Hl when the COVID-19 outbreaks occur As nurses are now in the context of COVID-19 pandemics, the medical staff cannot depend on patients’ relatives for non-treatment supports In Vietnam led to aVietnamese demand the consequence forhospitals, thecare medical ofParticularly, the staff COVID-19 that pandemic has to several adopt liasa central new concept of patient including Hanoi ICU in Medical University Hospital (HMUH) to designate comprehensive care as a dedicated unit for COV1D-19 care, which fulfils care accomplished based on the significance of patient safety without the support of patients' relatives 1.2 The nursing role in comprehensive care Nurses play a crucial role in the evaluation and implementation of comprehensive cate which contributes a lot to the patient healing process Nurses not only maintain the patient safety and decrease mortality but also provide extensive quality senices to reach their satisfaction Even though there are competent physicians present in the institution It would not be adequate when deficiencies the appropriate nursing care Nurses have 24-hour contact with patients as well as near to them, so they are seen like the frontline Accordingly, the patients have the orientation to expect more from them and nurses should also respond to patient’s needs with competence and compassionate access If the patient is denied appropriate care the treatment process is obviously compromised on this path assessing barriers and critical care units while providing nursing care is vital to identify the obstacles to tire nurses in their work environment and to improve the nursing senices at the same time Furthermore, in the COVID-19 stages, the duty of nursing is increasingly on a remarkable point Each patient has various characteristics and manifestations that require nurses to maintain critical thinking and make decisions properly Moreover, working in a completely new context to prevent the spreading of coronavirus that made nurses provide the accurate and promptly care for multiple patients including patient with COVID-19: suspected patient; non COVID-19 patient -w.- -ÍM QỈ Hgc V Hl 1.3 The barriers of nurses in comprehensive cares As we have known, since care has an effect on cultural, economic, and social factors, there are diverse baniers in the realization of care Especially in Asian countries, family traditions are maintained and highly respected, they assume one of the ancient conceptions that the sick hospitalize all trust and empoweT their relatives for no- treatment care Therefore, for a long time, the patient's family members occupy a significant position in the treatment process as well as improve the patient's mental health They play a vital role in helping patients with basic needs: observe and report the patient's condition personal hygiene, feeding, roll over, urine monitor, make a warm compress when the patient get fever, mobility support, mental support In addition, relatives will not be secure when we are not directly involved in taking care of and observing the patient Because of that idea, health workers, including nurses, have uncompleted the sufficient function, especially in the non-treatment care: basic personal needs, daily diets, and mental care Insuffici ent care has a strong relationship with the quality of care Furthermore, arise from reasons: most problems available related supporter to not resources completing from aand task the patient’s workload [30] relative; Aincreased recent the serious study lack 2016 of by staffing Nuian Potdar and his staff colleagues to comprehensive assessed nursing the barriers care in perceived ICƯ of Krishna by medical Hospital correlation Karad between The stresses result of that it shows are faced that by the doctors and barrier during to comprehensive working are care significantly in ICƯ In associated addition, with it the concluded supplies in tliat diverse attitudes workloads, among colleagues, less equipment, and fewer and nurses staff-patient [7] ratios are major barriers for doctors and Besides, healthcare providers are critical resources for patient health improvement that cannot be ignored Their health and safety are crucial not only for continuous and safe patient care, but also for control of any outbreak However, health-cate providers caring for patients during the severe acute respiratory syndrome (S ARS) and Middle East respiratory syndrome (MERS) outbreaks were under extraordinary stress related to high risk of infection stigniatisatiotL understailing, and uncertainty, and comprehensive support was a high priority during the outbreaks and afterwards Quantitative studies have shown that frontline healthcare providers treating patients with COVID-19 have greater risks of mental health problems, such as anxiety depression, insomnia, and stress [21] Frontline doctors and nurses with no expertise in this infectious disease face additional challenges as -w.- -ÍM QỈ Hgc V Hl they adapt to a completely new work environment in these stressful situations To our knowledge, no qualitative studies of the barriers of these healthcare providers have been published performing comprehensive care during the COVID-19 pandemic To assess the effectiveness of comprehensive care to them, it is necessary to gain insights into their experience and tlie barriers they have met 1.4 Comprehensive care in ICU'Vietnam To respond, the Ministry of Health issued Decision No 123/QD-K2DT in 2013 aimed at promoting comprehensive care in Vietnam Accordingly, continuous training materials and programs would be available for healthcare staff to update knowledge, skills, and promote attitudes towards comprehensive care [31 ] Unfortunately, the implementation of comprehensive care has only been constricted to highly standardized, private hospitals; and most state hospitals have been absent or incomplete of this healthcare model Nurses’ daily tasks in Vietnam are in nature, heavily involved in clinical treatment with little focus on non-treatment aspects The complex progression of the coronavirus disease (COVID-19) pandemic in Vietnam and the consequent demand to adapt inpatient cate provided to this health emergency led ICƯ in a few central Vietnamese hospitals, including Hanoi Medical University Hospital (HMUH) to designate comprehensive care as a dedicated unit for the COVID-19 care, will ch fulfils care accomplished based on the significance of patient satisfaction without the support of patients' relatives In the primary response to COVID-19 crisis in Vietnam, the ICƯ at HMUH has strived to separate illness inpatients from their relatives who have a high risk of the COVID-19 crisis from the public as much as possible This implementation is to minimize the ability of inpatients to get COVID-19 from the community The subsequent challenge was smooth operation with the new and -w.- -ÍM QỈ Hgc V Hl unstandardized model while coping with human resources shortage and work overwhelming Although designed there to accomplish are several these studies goals, on noailing models consensus of care exists on which consent, models when can reached, improse may clinical inform outcomes inservices healthcare the ICU Such offered system reform by increasingly efforts and popular helps toour shape the -w.- -ÍM QỈ Hgc V Hl 16 CHAPTER 2: SUBJECTS AND METHOD Study time & setting 2.1 The study was conducted in the ICU at HMUH, Vietnam from October to November 2020 Study participants 2.2 We recruited all nurses working in the ICU at HMUH who were accomplishing comprehensive care for patients during the COVID-19 pandemi c Inclusion criteria: • Nurses working in the ICƯ were directly practicing in comprehensive care for patients ■ Out of vacation time and during the COVID-19 episode ■ Nurses were willing to participate in ■ Nurses had the ability' to implement an online interview through Zoom meetings Exclusion criteria: • ICƯ nurse in an administrative position and head of ICC nurse ■ Nurses refused to participate in the study or online interview through Zoom meetings Study design 2.3 • A qualitative study was performed to describe barriers of nurses in comprehensive care and understand these nurses’ perspectives on comprehensive care during the COVID-19 pandemics in the ICƯ • Data collection was by group interviews via the internet based on the Zoom meeting platform In which, using sound and image recording function of this software Them the raw data was transcribed from the audio data to textual data • A31 audio recordings and transcripts were saved on a passwordprotected r-u -ÍM Qỉ ugc V Hl 17 computer Study instruments 2.4 We used a semi-structured questionnaire (15 questions) to collect information regarding study objectives The questionnaire was included three main sections: (1) General information (2) Barriers when providing comprehensive care for patients (3) Nurse’ perspectives about comprehensive care (1) General information: nurses were asked to provide information regarding age gender, working position, years of experience, education levels (7 questions) (2) Barriers when providing comprehensive care for patients: nurses were asked to provide their views and thoughts about what you every day to take care of your patients before COVID-19 pandemics? What you every day to take care of your patients curraitly when COVID-19 occurs? What are the differences between before and after COVID-19 pandemics in the way of caring for patients? What difficulties that you have been facing to take care of the patients during COMD-19 pandemics? What kind of support you receive during COVID-19 to be able to fulfill your current need of care? (5 questions) (3) Perceptions about comprehensive care: What is the idea of nursing care should be in the ftiture? What you think about the feasibility of integrating standardized comprehensive care protocols in your department? What factors/ conditions/ ingredients should be available to achieve comprehensive care? (3 questions) r-u -ÍM Qỉ ugc V Hl 18 Besides, another study tool was Zooin meetings Software and all participants had a computer or smartphone that can enroll the online interview through zoom meetings 2.5 Study parameters Table The study parameters Parameters Items Demographic Al Gender information A2 Age A3 Marital status A4 Education level A5 Years of experience A6 Working position Bl Routine nursing activities before the COVID-19 Barriers of comprehensive care Information pandemic B2 Routi ne nursing activities during the COXTD -19 pandemic B3 The difference nursing care between before and during the COVID-19 pandemic B4 Barriers of nursing perform comprehensive care durin g the co VID -19 pandemic B5 Kind of supports the ICƯ nurses have received durin g the COVID pandemic Perception of Cl comprehensive care The ICU nurses' perspective about the future nursing care model C2 The feasibility of integrating a standardized comprehensive care protocol C3 The expected factors should be available to achieve comprehensive care r-u -ÍM Qỉ ugc V Hl 19 Data collection 2.6 - Data was collected through group interviews via an online software called Zoom meeting In which this study used sound and image recording function of this software during the interview time - All of the participants were randomly divided into two subgroups that were consistent with two interviews - In the interview implementation, after introducing the study purposes, the nurse was invited to take part in the study All online interviews were conducted in a private room to make sure a comfortable environment and confidentiality Interviewers were first to warm up the conversation with greetings The interview heavily, but not merely, depends on aforeconstructed questions The interviewers based on emerging ideas, information from nurses’ responses to ask additional questions to shape a frill picture of the research objectives Data collection was continued until the researchers were confident that no more new ideas, concepts, and categories emerged - After the interview, we obtained two audio and video recordings The next step of the data collection procedure was to transcribe the raw data from audio data to text data In addition confidentiality was assured by using numbers instead of names (eg Nurse Nurse 2, etc) and removing identifying information from the transcripts Concludingly data analysis.the researcher had text data to facilitate r-u -ÍM QỈ Hgc V Hl 20 Choose the data collection method Group interview Plan the data collection procedure Sampling: all ICƯ nurses at HML'H divided two random groups Location: an online software (Zoom meeting), times Time: November and November 6.2021 Study instrument a semi- structured questionnaire (15 questions) Management data: using sound and image recording function via Zoom meeting Implement the Interview Follow up the data collection procedure Transcript the audio data Transcript from original audio data via Zoom meeting Having available text data for analysis Figure The process of Qualitative data collection r-u -ÍM Qỉ Hgc ugc V V Hl 21 2.7 Data analysis All raw data was recorded and precisely transcribed Using Excel software, the data was synthesized and interpreted by applying a content analysis strategy First of the data analysis process, the researcher read all tire transcript several times to gain an understanding of meanings conveyed, identifying significant phrases and restating them in general terms, formulating meanings and validating meanings Second, labeling of codes was conducted using the words of participants and perceived concepts of the text Similar codes were placed in one category that called “meaning unit” and formed the categorization of codes The categories with similar concepts were located around a common and core axis Then, categories withobjectives similar concepts and similar a subjects sub-themes were indicated into "a specific "sub-theme" theme”Summarizing to develop various full description ofmerged study r-u -ÍM Qỉ ugc V Hl Designing and accomplishing study-tools Study design and sampling Data collection procedure Data analysis Conclusion 2.8 Figure 2 The Qualitative research process The trustworthiness of a qualitative research Trustworthiness or rigor of a qualitative study refers to die degree of confidence in data, interpretation and methods utilized to ensure the quality of study * 2.8.1 Credibility of this study The data and processes of analysis address the intended focus on nurses' experience about the implementation of comprehensive care, particularly the barriers and perception of them in ICƯ at HMƯH in the context of the COVID19 pandemic Besides, choosing the focus group interview allows for the exchange of ideas, opinions, and viewpoints that might not be revealed through surveys or interviews which helps researchers better understand the topic at hand F urthermore one of the crucial issues in the study method is select the most suitable meaning units The analysis included, reading the transcript several times to perceive meanings conveyed, identity significant phrases, and had the consult from experts Moreover, all of the categories and themes cover data were sincerely reveal by ICƯ nurses and they are completely responsible for all their speech associated with comprehensive care during the COVID-19 pandemic Triangulation has been intimated as "the process of corroborating evidence from various individuals, data types, or data collection methods" In particular, data sources might be interviews, observations of this meeting (including nonverbal expressions of participants), information got from semistructured questionnaires Triangulation can also mention the collection of information from multiple types of participants about the same phenomenon The effect of the triangulation method is to create a more holistic picture of the phenomenon that are studying and to prevent over-reliance on a single method or data collection source 2.82 Dependability of tliis study Dependability mentions the extent to which approximate findings would be obtained if the study were repeated However, variability should be expectant in qualitative studies The best strategy to assist the dependability of a study is to guarantee that the method is described in sufficient derail so that it can be reproduced by others and any restrictions discussed Triangulation of the methods will also improse the dependability of the results 2.83 Transferability of this study Transferability indicates how well research results can be applied to other similar organizations Tile ability of others to appreciate whether tlie findings are transferable depends oil a detailed description of the study context, the selection of participants, and the results This is associated with a "thick description" 2.9 Ethical consideration - The stud}' subjects were explained clearly about the purpose of the study before the telephone interview Tile questionnaires were given only when subjects agreed to participate The right to withdraw at any time was explained clearly to the participants - The study tool was not involved sensitive or intimate problems and did not affect the subject’s emotion - Collected data was used for research The results of the study were proposed for improving the quality’ of nursing care, not for other purposes Participants’ information was keptrewaling secret names All information and comments personal information were encoded without and CHAPTER 3: RESULT 3.1 General characteristics of participants Overall 12 participants were enrolled in the sample Demographic characteristics of all participants were detail shown in table 4.1 and table 4.2 The age of all ICƯ nurse in the ICƯ at HMƯH ranged from 25 years old to 38 years old which were disided into groups: 20-30 years old 31-40 years old and no one in the period of above 41 Among participants, two-thifds of the participants (S) were female and were male There is a balanced ratio between married nurse and single nurse Furthermore, the participants who had been reported to be college level was and for other participants in bachelor's degree was 11 All of them had more than 1-vear of experience in the ICƯ Besides, about the job position, they totally in particular had the analogous working as nurses, and no one was head of the nurse or nurse supervisor Table Participants' demographic information Age Gender Marital Work years status Education Job level position More than Bachelor’s Nurse years degree More than Bachelor’s years degree More than Bachelor’s years degree 1-2 years Bachelor’s experience years Nurse Nurse Nurse Nurse 30 29 29 25 Female Female Female Female Single Marred Marred Single Nurse Nurse Nurse degree Nurse 29 Female Single -ÍM CỊỈ ugc V Hl More than Bachelor's years degree Nurse Nurse Nurse Nurse 31 33 2Ố Male Male Female Married More than Bachelor’s Nurse years degree Married More than College Nurse Single years • 1-2 Mears Bachelor’s Nurse degree Nurse Nurse 10 38 26 Female Female Married Single More than Bachelor’s years degree -2 years Bachelor’s Nurse Nurse degree Nurse 11 33 Male Married More than Bachelor’s years degree Nurse • Nurse 12 25 Female Single 1-2 years Bachelor’s degree -ÍM CỊỈ ugc V Hl Nurse Table Characteristics of the study participant Characteristics of the Study Participants Variables n 20-30 31-40 41-50 Gender Female Male Marital status Single Married Others Education level Intermediate College Bachelor’s degree 11 Postgraduate qualification Work experience Less than year -2 years More than years Job position Nurse 12 Head nurse Nurse supervisor 3.2 The barriers of nuises performing Comprehensive care In Intensive -ÍM CỊỈ ugc V Hl care unit during the CO VID-19 pandemic Analysis of the interview data led to identification of five Comprehensive main themes reflecting during COVID-19 the ICƯ pandemic nurses’ (Table barriers 3.1) Overall, about nursing participants care among Comprehensive expressed positive care and attitudes acknowledged integrity the as growth an important of the element professional of professionalism model worldwide significant and satisfaction barriers to Otherwise, the they believed and completion there were of thisjob organizational, model Although and stressors an array of from individual, environment issues was discussed discussions during revolved the interviews, around organizational the most frequent barriers (insufficiency unprofessional of structure human resources; of ICƯ) nursing Because workload: there was the applied experience athe novel in their modelparticular Comprehensive medical care field, After nurse years had of to take from care that of seen patients in their with daily aoptimization condition practice that is different Table 3 Maili themes reflecting the barriers of nurses performing Comprehensive care in ICƯ during COVID-19 pandemic Themes The baniers of nurses performing Comprehensive care ill ICC* during COVID-19 pandemic Insufficiency of human resource Overwhelmed and stressed by the nursing workload The unprofessional structure of the ICƯ Non-cooperation of the patient's relatives The uncertainty and anxiety of being infected COVID-19 and infecting others 3.2.1 Barriers related to Insufficiency of human resource The first category of themes •’Barrier related to the insufficiency of human resource", consisted of five sub-themes relating to the mismatch between the number of nurse staff compared with the number of patients and the huge workload nurses had to implement during the COVID-19 pandemic and adapting to a new working environment without the support of patient’ relatives -ÍM CỊỈ ugc V Hl Table Barrier related to insufficiency of human resource Meaning unit Sub-theme A working day includes Theme Each nursing shift lias Barrier nurses'morning shift; nurses/shift 2-3 nurses related to Oil duty in the afternoon, evening, insufficiency and on weekends of human The ICU at HMƯH has a maximum The of resource ratio of 10 patients They divided the nursing/patient number of ICU patients to perform averaged 1/5- 1/3 in a the nursing care that accounted for 3- shift patient/ nurse; shift Before and after COVID-19 nursing The amount of workforce was still in a shortage, on workload increased, the other hand, during the COVID- and the number of 19 period, the amount of nursing nurses remained the work required to increase // the same previous time nursing J patient ratio was 1/5 when Therefore the there are no specialized procedures personnel problem is such as implantation dialysis .: heart compressions, exacerbated tubes, open When results, there are specialized ones, the ratio maybe is 1/9 Nursing found that large workloads Lack of manpower while insufficient nursing numbers -ÍM CỊỈ ugc V Hl negatively affects the 30 resulted in inadequate patient care and quality of care; monitoring as before pandemic, negative COVID-19 increased risk of affecting the medical errors quality of care Thus, it has a high risk of causing medical errors Nurses eat erratically or skip meals For example, a shift from 7:00 am IO 3:00 pm Nursing staff is limited, someone skips lunch and works the workload is large, continuously until the end of the shift some nurses often skip The reason is that the human resources meals so as not to are thin and overload working, they try interrupt work and to get enough work done before complete tasks during finishing a shift time Conversely, if a shifts// or due to fatigue nurse goes to eat the other person will have to monitor and take care of all 10 patients at the same time / / Maybe the mealtime only lasts for 15 minutes, but because of fatigue, they loss of appetite InCOVID-19 pandemic, they could notnurses handle themto without the stress shortage of complaint staff The Leading nursefrom to-patient the problems ratio was with indicated to careand for to more be athan problem three with patients, the from sometimes 1/3 1/5 having even 1/9: "For example, there are nurses taking care o f patients, but of which there are 7-8 ventilated patients, when I go to the pharmacy unit to take medicine, the other nurse will look after all patients ■■ (Nurse 1) "In my opinion, with nurses that attend to JO patients It w ill not be possible to detail each patient It is just preliminary of the most essential things like changing diapers, pouring urine, but for rolling patients, every hours and lung flutter each patient that is extremely difficult to that with nurses" (Nurse 11) That is a familiar estimation with Nurse She said that: "Normally, like before the COVID-19 pandemic, there were family members to support such as patients' basic needs like changing diapers and eating, we will have more lime to other things Nowadays, the number of nurses is still the same, but they r-u -ÍM Qỉ ugc V Hl 31 have to more work, so the time of wary and specific care for each patient will be reduced " Participants reported that they were encountering problems with provision of nursing staff in a large ICU The situation of having inadequate nurses made a big concern regarding to the quality of nursing care In particular, it can affect the safety' of the patient and themselves in the medical field: "More and more work, insufficient human resources, patient care and monitoring are not as close as before and the quality of care will certainly decline Since these will cause a lot of shortcomings, generally I cannot commit to getting every job perfectly done and shortcomings in the medical field are dangerous It's possible that medical mistakes can happen" (Nurse 4) 3.22 Barrier related to overwhelmed and stressed by the nursing workload r-u -ÍM Qỉ ugc V Hl 32 The second category of themes “Barrier related to overwhelmed and exhausted by the nursing workload", consisted of four sub-themes regard tothe workload and sưesses of performing comprehensive care for patients during the COVID-19 pandemic and adapting to a new working environment without the support of the patients relatives Table Barrier related to overwhelmed and exhausted by the nursing workload Meaning unit Sub-theme Theme A working day includes shifts One nursing shift Barrier related to from 7:00 am to 2:00 pm 2:00 pm - lasts 8-10 hours overwhelmed and 9:00 pm: 9:00 am to 7:00 am of the The next day average of exhausted by the working hours was nursing workload 40-48 hours/week r-u -ÍM Qỉ ugc V Hl 33 In COVID-19 the nurse perfornKd Nurses completely 100% of the tasks "patient's basic perform tile patient individual needs" such as changing care diapers, changing gas without pouring support of patient's urine, bathing, washing, feeding the relative patient with alert patients by mouth, COVID-19 rolling the patient excepting to the support of family members // with patients who monitor urine hour/time requiring the nurse to pause the current work, return this patient to weight urine and pour urine for the patient indicated by follow-up causes time-consuming overlapping, and interruption of nursing work // Family members are not allowed to enter the ICƯ department exclusive of discussing the patient’s condition with the medical staff// They the are not permitted to contact with patients and assist with basic care for patient r-u -ÍM Qỉ ugc V Hl during 34 In COVID-19 nurses haw taking In the COVID-19 care of 10 patients so they cannot pandemic, nursing / perform as detailed as before patient ratio = 1/5 Accordingly, due to over workload, with the time to focus on one patient will be less For example, changing position each patient every hours, doing vibration each patient steadily is very difficult In the case of having 2-3 severe patients, nurses cannot be close to each patient, but only preliminary respond to the most essential needs of the patient such as feeding, changing diapers, pouring urine and specialist care more workload the patient affects quality of care No guaranteed details of each patient In the case of severe patients with mamprocedures, the nursing only gave preliminary processes Only when the nursing work did not response “patient's basic have many procedures, they needs” r-u -ÍM Qỉ ugc V Hl individual 35 will have more time to care for all processes patients in detail Some nursing for have Changing procedures changed: submitting a blood sample adding and some f test item of a patient with nursing care and suspected COVID-19 infection administrative should be placed in a separate box procedures labelled "suspected patient with procedures to suit COVID-19"; intubation the is process changed in of the COVID-19 the epidemic intervention device to avoid drops conditions from the patient, protective gear of the health-care worker involved in the insertion process Some new procedures: medical reporting for patients and patient family members When family members were not present in ICU it took a long time to contact them to buy and provide some items and items that were not available in the unit For example: milk, diapers, towel dry toothblush, paper face self-help medicine for patients Nurses in COVID-19 were unable to monitor a patient continuously r-u -ÍM Qỉ ugc V Hl 36 they need to tie die patient’s limbs, in some cases the patient tries to remove gastrointestinal catheter, withdraw the infusion line // there are patients who have to reset up GI intubation to 10 times In some patients without family The morale of members by side, their moods went some patients is down, they become sad, unstable, affected when their develop a state of delirium The relatives are not consequences were consisted of around; Some of pulling the line urinary their unintentional catheterization, nasal gastric tube, behaviours and especially danger when they endanger withdraw the endotracheal tube The themselves and nurses must re-take care and fix the interfere with limbs as needed, while nurses had nursing care many other patients to perform Raised many nursing care jobs for nursing In spite of fact that healthcare providers carried on with tlieir duties, they still experienced their own physical and emotional stresses, tensions that are common to other people None of those nurses had previous experience with an infectious disease and entering the isolation ward was viewed as oppressive and stressful Through disinfection efforts, and isolation measures ICU managers implemented restricted zoning by having a proposed action which is a limitation of the patient’s relatives visited Furthermore, making numerous modifications r-u -ÍM Qỉ ugc V Hl 37 and supplement to the available care procedures to accommodate COVID-19 conditions ■Jr !CU since taking comprehensive care in the COVID-] period, ue have to perform a lot of work, most of the time, I feel very stress when my tasks cannot be done during the rime shift " (Nurse 2) Explaining the reason made her feels stress She said "Previously, the patient’s family came to support me many things, but now there are problems such as feeding the alert patient by mouth, which I also have to Moreover, there are severe patients who monitor urine for ì hour/time have to remember and pour urine out while I have to fake care of many patients For example, when I'm in the middle of doing feed to another patient I have to stop ứ and pour urine This means that my daily tasks have to overlap because of unexpected work Therefore, I'm doing this job I have to stop a little bit, assess which one is more urgent, I it first So interrupted, all the jobs are oxer lapping so there is a lot of stress "