Adapting protocol to the evolving context of practice was identified as the core category that delineates how emergency nurses overcome the uncertainty and change in various areas of their practice during epidemics. Four interplaying sub-categories were identified: (1) completing a comprehensive assessment, (2) continuing education for EID management, (3) incorporating guideline updates and (4) navigating new duties and competencies. These categories represent the strategies adopted by the emergency nurses to address uncertainty and changes during EID management.
Adapting protocol to the evolving context of practice
Emergency nurses are subjected to a work environment constituting changes and uncertainties in different aspects of emergency care provision during an EID outbreak. To address the diverse needs arising from the evolving context of practice, emergency nurses are required to showcase their capacity to adapt and embrace changes, depending on the situation. The following comment illustrates how an experienced emergency nurse valued the importance of being adaptable when responding to untoward incidents during EID management:
“Various unexpected issues that demand our action come all of a sudden, and we are unable to stop or control them. At this moment, it is time to examine our ability to stand the test of these challenges. It tests our leadership, our problem-solving skills, and our ability to improvise. In addition, it challenges our critical thinking skills and decision-making abilities. These are all crucial as we work in the accident and emergency department, especially in the midst of unpredictable and unforeseen events.” (P16)
This view was echoed by another participant, who indicated that technical solutions were inadequate and unavailable for emergency nurses to handle unexpected issues while performing EID duties. The participant remarked that it was crucial for emergency nurses to be capable of swiftly adjusting to peculiar situations by identifying alternatives on an impromptu rather than on a prepared basis:
“It could be chaotic and problematic in managing EID. We are not able to predict what is ahead waiting for us to handle. Things can happen in a way that is poles apart from what is written in the protocol.” (P14)
In addition, the findings suggested that the daily duties of emergency nurses amid an epidemic event were largely affected by the mostly unpredictable individual patient’s circumstances. The uncertainties surrounding a patients’ condition and the nature of outbreak situations posed tremendous challenges to the physical, emotional and psychological capacity of emergency nurses to adapt existing knowledge, skills and attitudes to various circumstances of the patients. One participant shared their experience of an incident that occurred during the Ebola virus disease outbreak. In this situation, a patient with suspected infection displayed uncooperative and aggressive behaviour:
“There was once a suspected Ebola case transferred to our department via ambulance. The patient had developed signs of infection; therefore we considered him to be high risk and arranged an isolated room for quarantine purposes. But then the patient started to be uncooperative and aggressive, perhaps because of communication problems, as the patient was from an ethnic minority and there was no interpreter available at that moment. Suddenly he turned violent and assaulted our staff and we had to subdue and restrain him, while we had no time to gown up in PPE (personal protective equipment). At that time, we were so helpless and we were afraid of being infected. The guidelines and protocols did not mention what we could do in this situation, and we had to count on ourselves.” (P14)
This incident showcases a situation in which emergency nurses encountered an unpredictable and unexpected event that, as described by some participants, ‘stirred up troubles’. Instead of following the established protocol, the emergency nurses were required to develop their adaptive capacity to acclimate to the evolving context of practice amid EID management.
(1) Completing a comprehensive assessment
The findings revealed that a major challenge encountered by emergency nurses in managing EIDs was the uncertainty surrounding the patient and disease context. Such an uncertain situation could create ambiguity among emergency nurses in achieving the goals and objectives of their practice. In addition, participants stated that they doubted whether they had been well-prepared for handling an epidemic and questioned the relevance of their prior knowledge and skills in managing EIDs. Some participants expressed the belief that the most pertinent way to resolve uncertainty was to obtain relevant information on how to address any erratic situation. Indeed, gathering up-to-date information was considered crucial by emergency nurses to acquire a general picture of the nature and progress of an EID scenario. This strategy enabled them to comprehensively assess their workplace to orientate themselves to the circumstances. One participant succinctly highlighted the importance of obtaining relevant information when trying gaining familiarity with an EID scenario:
“It is of the utmost importance that you know what is happening. As long as you understand the situation, you realise the problem. You have to acquire the latest information and maintain an up-to-date understanding of the situation.” (P16)
One of the major concerns raised by the participants surrounded the quality of the information, as some of them pointed out that the information they received was not standardised. Two participants stated that the information provided by their colleagues, which included disease information, infection control guidelines and patient logistics protocols, was sometimes inconsistent, leading to confusion. Although they worked in different hospitals, these two participants held similar opinions about the inconsistency of the information they received. One of the participants described the problem as follows:
“The information could sometimes be regarded as ‘hearsay’. Perhaps one staff member had said something about the disease, then others started to discuss and circulate the information. However, no one had confirmed the creditability or sources of that piece of information. The information might be distorted, exaggerated or even misleading. However, we do not have an official and standardised source for obtaining information, and therefore, hearsay persists among staff.” (P20)
Many participants highlighted that instead of depending entirely on the provided information, which could be inconsistent, personal alertness and vigilance were also required in addressing the unclear situations they were facing. In their everyday work, emergency nurses serve as gatekeepers who are closely connected to the community. Their frontline position helps emergency nurses to collect clues on disease trends and progression and perform a comprehensive and first-hand assessment of the general disease situation. The comment below illustrates how one participant recognised the outbreak of H1N1 influenza by engaging in routine practice:
“You know about the disease situation and progress at work, especially if you are the triage nurse. There were a large number of patients attending AED and eight out of 10 had similar flu-like symptoms. You would then realise and be able to tell, there was something wrong, it was the influenza that was causing this — you experienced it and sensed it. This sense did not merely improve your alertness, but also provided you with the whole picture of the outbreak, including the severity, the magnitude and the extent.” (P17)
(2) Continuing education for EID management
To respond to an epidemic event, the participants highlighted the importance of acquiring relevant knowledge and skills to bolster their preparedness both theoretically and practically. Indeed, EID management requires emergency nurses to demonstrate proficiency in various skills and techniques. Several participants reported that specific skill sets, such as clinical assessment skills and precautionary measures, enabled them to accomplish various unforeseeable tasks in an effective and appropriate manner during EID management. One advanced practice nurse highlighted the necessity for emergency nurses to develop the skill of rapid and accurate clinical assessment for patient surveillance:
“Sometimes there are junior colleagues making mistakes in simple tasks while handling EID cases. The main reason is that they are not familiar with this type of knowledge. I often ask them to do some infectious diseases revision. This is basic for emergency nurses. For example, being able to identify the signs and symptoms of an EID is the most important task in EID management, but if the nurse did not have the related knowledge, how can one differentiate infected patients from the others?” (P17)
Because of the importance of obtaining pertinent knowledge and skills, various resources, such as workshops and drills, are available to emergency nurses to facilitate learning on the required techniques to optimally engage in EID management. The participants described that such training courses offered opportunities to AED staff to familiarise themselves with the process of managing epidemic events that were likely to occur. One participant shared their experience of an Ebola drill as follows:
“There was an Ebola drill in our department not long ago. We participated in a simulation for the admission of a patient with confirmed Ebola infection into the AED. It started from the very beginning, from receiving a phone call from the ambulance for the admission of the Ebola case, to triage, to the treatment and arrangement. Staff were assigned to different roles in the drill, such as triage nurse and nursing officer in-charge. We can learn and reinforce the importance of infection control through the drill. We will know how to manage this kind of contingency if we really encounter such an issue in the future.” (P16)
Indeed, participants agreed that training in a simulated environment assisted their preparation for an epidemic event and enhanced their performance to respond to an EID scenario. Nonetheless, the participants highlighted that it was also necessary for emergency nurses to accumulate clinical experience to establish their preparedness and proficiency in EID management. They described such experience as irreplaceable and that full proficiency would not be possible by only participating in drills and education. The participants also stated that prolonged engagement in clinical settings benefitted emergency nurses, as clinical wisdom can only be developed by being immersed in the substantial aspects of everyday practice. The following comment illustrates one participant’s opinion on the value of accumulated clinical experience on establishing preparedness in managing an unanticipated situation:
“In the management of EIDs, there are enormous unexpected issues that one might have no idea about how to handle, unless one had accumulated clinical experience or there were others who could share their own experience. It would be difficult for a junior emergency nurse, who had never come across similar issues in reality, to figure out a solution, even if they had attended workshops or drills before. Only if they had actually experienced this type of issue before, could they identify the possible difficulties that might emerge. Then they would have learned from the experience and be ready to handle similar situations in the future.” (P22)
(3) Incorporating guideline updates
The development of an EID situation could have enormous effects on the implementation of precautionary measures. Although stringent infection control recommendations are established to address the exacerbation of the disease situation, the participants valued the relevance of these accelerated infection control measures in protecting both healthcare personnel and the public from EIDs. However, guideline changes for an EID situation also impact emergency service delivery. Some participants did not feel confident about their readiness to adhere to guideline changes due to lack of practice, even though instructions were provided. They commented that there were often distinct differences between new recommendations and the practices they had been accustomed to following, which caused additional difficulties in successfully implementing the new recommendations. One participant expressed concerns about adhering to updated PPE guidelines in an Ebola response and depicted an example of the challenges that emergency nurses might encounter due to guideline changes:
“There are new recommendations on the standard of the PPE kits for use in handling patients with suspected or confirmed Ebola infection, including a new gown, thicker gloves, additional rain boots, and an extra hood. It is different from the one we are used to using when dealing with other infectious diseases. Not only the equipment but also the methods and sequences in equipping and removing the gear are totally new to us. Although we have been told and taught in workshops how to utilise the new PPE, it is still difficult for us to be readily familiar with the new recommendations without an opportunity to practice.” (P17)
To incorporate guideline updates into practice, participants had underlined the necessity for taking into account the reality of clinical situations and making practical adjustments to new protocol and recommendations accordingly. The following comment gives an example on how emergency nurses might experience the adjustment process:
“Learning from new guidelines and recommendations is like peeling an onion — you peel off something layer by layer. What is left behind is something that could be incorporated into clinical practice. We should understand that what we have learned or adopted formerly is valuable and what we are doing now is renewing it to fit the situation. We do not have to do everything by the book. Instead, we should adopt the process and adapt to the situation.” (P26)
Indeed, many participants suggested that it was of paramount importance to value both their experience and the new recommendations through careful adjustments and modifications. Emergency nurses might develop a tailored set of practices by integrating new recommendations into their experience, enabling them to adapt to the novel needs of EID management. One participant illustrated their experience in adapting to changes in routine as follows:
“When handling a new situation and coping with new challenges, your experience is always invaluable. However, it is important to understand the core intentions embedded in the new guidelines and recommendations and combine what I have learnt with the new knowledge. I would filter the new guidelines and incorporate them alongside my original set of practices, as long as those guidelines do not violate the basic principles of what I have established from my clinical experience. It is the essence of the new guidelines that I should take into account instead of rigidly adhering to any recommendations.” (P14)
(4) Navigating the new duties and competencies
During an EID event, the scope of emergency healthcare services is broadened such that emphasis placed on infection prevention and control, in addition to the usual life-saving practice of emergency care provision. Although all participants acknowledged the participation of emergency nurses in an epidemic event response, some encountered difficulties incorporating their extended duties into practice. Several participants commented that performing the extended range of responsibilities was challenging because of a lack of clarity surrounding their scope of practice during an epidemic event. For instance, one participant, who was relatively new to the emergency care setting, expressed the following concerns about performing the responsibilities of an emergency nurse during an H7N9 avian influenza epidemic:
“In the course of EID management, I have a feeling that I am not working in an AED. I formerly expected that an emergency nurse was responsible for triaging patients according to their conditions and offering care to those who were in critical and urgent need. But now my duty has changed all of a sudden and I am mainly assigned to duties on infection prevention. It is true that the guidelines and measures for disease prevention and infection control have been put in place, but the problem is, I personally am not yet in place.” (P12)
On the same topic, a participant who served as a department operations manager and was in a high managerial position highlighted the importance of emergency nurses to maintain an open mind in the face of significant changes to work practices. This participant addressed their views as follows:
“Ideally, we should do everything we can for the patients, and this is what we always do in AEDs. At the same time, we should also consider the outcomes and consequences of our actions and interventions. There are various issues we have to consider when making a decision, and therefore, we have to be flexible and remain open on these grounds rather than sticking to the same old rut all the time.” (P26)
Some participants agreed that working adaptively and flexibly was essential for emergency nurses to navigate their altered scope of practice to accommodate the evolving needs during EID management. They generally acknowledged and displayed an acceptance of the extended responsibilities and endeavoured to cultivate adaptiveness and assimilate infection prevention into their regular work practices. One participant commented on this point as follows:
“Sometimes one should allow changes to take place and show openness towards the changes. Now, I can say the practice of infection control has seemingly integrated as a usual component into my emergency care practice, regardless of the alert level and disease situation. It is a process that takes time.” (P13)