Strengthening the WorkForce for Family Island Nurses during Pandemics

Strengthening the WorkForce for Family Island Nurses during Pandemics

History of Family Islands in The Bahamas

Historically, the story of the Bahamas is tragic, spanning from slavery trade to introduction of plantation systems for the African slaves and history of piracy[1]. Despite its murky past, the Bahamas is a well-endowed region with an agreeable climate and picturesque beaches ideal for tourism, which is among the leading income-generating industries in the region. North of Cuba and Hispaniola lies archipelago comprising of more than 700 islands, out of which 20 are inhabited. The archipelago stretches more than 500 miles between Grand Bahama Island and the southern coast of U.S. State of Florida[2]. The capital of the Bahamas is Nassau and is located on a small but important island, new Providence Island. The island others that New Providence is collectively known as the Family Islands. They include Grand Bahama, Andros (the largest island in the Bahamas), Abaco, and Eleuthera[3]. Historically, the population of African descent has inhabited the region for decades given the slave trade that occurred in the 19^th and 20^th centuries[4].

Significance of the Issue

Developing countries such as the Bahamas are reported to be among the nations least prepared for pandemics, including the recent COVID-19 outbreak[5]. The conclusion is based on a Global Health Security index 2019 that rates a country’s healthcare system on various factors[6]. Among them is the prevention of emergence of the release of pathogens, early detection and reporting for epidemics, sufficient and robust health system to protect health workers and rapid response to and mitigation of the spread of the epidemic[7]. Based on the analysis, the Bahamas ranked below average in six out of the seven categories ranking it at 67^th out of 195 countries[8].

The current Pandemic on COVID-19 is proving to be a difficult one given that no cure or vaccine or non-existent effective mitigation factors exist. As such, the Bahamas is at high-risk to increased infections and the resultant pressure on the healthcare system[9]. Primarily, the Bahamas is a travel destination for countries globally due to tourist and financial-related activities. Compounding the limitations of the country’s healthcare system according to the Global Health Security index 2019 and travel pressures to the region, the country faces an unprecedented epidemic that is currently grappling the planet[10]. Therefore, Family islands are at a great vulnerability when it comes to healthcare security regarding pandemics.

Background/Historical Origin

The world, in the past and current, has witnessed a common epidemic-cum-pandemic with a defined origin. Recent events regarding MERS, SARS, and COVID-19 originate from a virus family known as Coronaviruses. In 2019, a novel coronavirus was initially reported in Wuhan, China. Speculations regarding the origin of the virus were from the animal- a zoonotic characteristic in which a virus can be spread from animals to humans[11]. In the past, the world has also witnessed epidemics caused by the same coronavirus, including Middle East Respiratory Syndrome (MERS) in 2012, and Severe Acute Respiratory Syndrome (SARS) in 2002.

SARS cases were reported to be specific inpatient infection based on age where those above the age of 65 were more likely to die compared to those under 24 years of age. At least 8 000 fatalities were reported in 2002[12]. On the other hand, MERS originally reported in Saudi Arabia affected at least 2 000 people in 21 countries with at least 8 00 deaths[13]. The connection between these previous epidemics is not yet known, but what is true is that it causes mild to severe symptoms in humans that can be fatal. Hence, the suitability, effectiveness, and efficiency of a healthcare system is paramount, especially with the recent COVID-19, which has surpassed 1 million infections globally[14].

Epidemiology of MERS-COVID

According to reports, there are close relations to the identical sequences of COVID-19 to previous epidemics of SARS and MERS. According to Park et al., sequenced data indicates that COVID-19 has a 50% shared identity with MERS[15]. Regarding the infection rates, studies have shown that the reproductive number of MERS-COVID is greater than 1. What this data means is that R0 is the growth rate of an outbreak and the total number of individuals affected at the end of an outbreak. When R0 is lower than 1, then there is a sustained epidemic, when it is higher, vice versa[16]. Based on the disease clusters of MERS, the incidences are less given that there are cases of underreporting about this illness[17].

As for COVID-19, the geographical distribution has reached 1 M with China, original case report, indicated more than 80 000 cases[18]. More than 195 countries have reported on COVID-19 infections. In the United States, more than 50 states and four territories have reported infections. However, with regard to human-to-human infection, SARS-CoV 2 (virus associated with COVID-19) is reported to occur in humans spread through respiratory droplets[19]. The virus is also reported to last at least three hours. Viral RNA is reported to be higher as soon as symptoms are detected in infected people[20]. Asymptomatic individuals have also been noted concerning COVID-19. Overall, the risk of transmission of COVID-19 is dependent on duration and type of transmission, preventative measures used, and individual factors. Secondary aspects such as household contacts, healthcare setting, and personal protective equipment are linked to the spread of the illness[21].

Flattening Epidemiological curve (use map of inhabitant islands of the Bahamas and how the spread can be contained)

Figure 1: Flattening Epidemiology Curve. Source: https://cdn.mos.cms.futurecdn.net/kprY6iosupNFc6CXYEvQAG-650-80.jpg

Figure 2: The Family Islands of the Bahamas. Source: https://en.wikipedia.org/wiki/Out_Islands

Pandemics can have a long-term effect on the Family Islands in the Bahamas if critical care is not implored at this time. According to scientists, the best and effective way is through a flattening curve concept. A flattening curve concept expounds on health-based measures countries implement to reduce the spread of infections. Among them is the social distancing guidelines[22].  The curve, according to scientists, refers to the projected number of people who will contract the virus over a period of time. It is estimated that the curve in the Family islands could be steeper compared to other developed nations. As such, the virus may spread exponentially[23]. The total number of cases may skyrocket, as seen in Figure 2. Consequently, the infection curves may be steeper with a steep fall, given that the infection may infect a substantial population. The quicker the infection rates, the faster the local health care system gets overwhelmed beyond its capacity[24]. If the islands take precautions advised by the World Health Organization and the Center for Disease Prevention and Control, then the expected flatter curve will be noticed. It means that a small number of people will get infected over a longer period of time. Therefore, the slower the infection rate, the less stressed the health care system[25]

Analysis of the evidence of the problem or issue-based upon data, quantitative and/ qualitative data

The alarming failure in the global supply of personal protective equipment and new test kits altogether present unprecedented overwork linked to global staff shortages highlighting the vulnerabilities of the nurses[26]. According to the United Nations 2020 report on the vulnerability of nurses, the impact on the frontline workers spans from mental, psychosocial, socioeconomic, occupation, and health factors[27]. The report further indicates that nurses have experienced burnouts and unprecedented levels of overwork, especially those in intensive care units and administration. On the extreme ends, it is also reported that levels of infections among frontline workers are raising alarm bells around the world. It is estimated, according to the UN report[28]That 9% of infection rates were documented in Italy alone, while Spain recorded 14% infection rates. In China, more than 100 health professionals fatalities were reported[29]. Due to the risk that nurses are exposed to, strikes reports in regions of Zimbabwe and Kenya are indicated[30]. The general consensus is that lack of provision of PPE and training in regard to pandemics such as COVID-19 is to blame. Therefore, the overall perception is that nurses are seen as risks and not the solution regardless of their primary role in caring for the infected and the community’s welfare.

Aims and Objectives of this Protocol

The aim of the protocol is to provide a reference protocol not only for the present but for future endeavors with the need to strengthen the workforce for Family Island nurses during pandemics.

Primary objective: Create a Family Island Protocol that targets nurses during pandemics such as COVID-19.

Specific Objectives:

1. Provide a human resource management protocol during the post-pandemic period.
2. Provide information regarding implications for Family Island nurses on future improvements for epidemics/pandemics.
3. Recommend staffing measures regarding the pandemic crisis in the future.
4. Providing overall care-package information on psychological support, legal considerations, communication protocol, and incorporation of telehealth technologies for essential workers.
5. Recommend a protocol for caring for patients, including surveillance, facilities, care for at-risk populations, and equipment and supplies required during pandemics/epidemics.

Human Resource Management during the Post Pandemic Period

Human resource management during a post-pandemic period is necessary to guarantee improved morale, reduce burnout, and increased performance among nurses. To achieve this, the Family Island protocol recommends both technological and human resource management actions. The first criteria require:

• The decision to reduce hours of operation or close some or all the locations based on the directives from local and state health.
• The decision has to go hand in hand with the monitoring of staff available at the specific locations to decide if the locations are adequately staffed to provide essential services[31].
• Staff relocation can be necessary on a temporary basis, depending on staff availability.
• During the post-pandemic period, measures including social distancing, testing of staff to determine new infections and exploration of flexible working hours to reduce distance between employees should be considered[32].

Given the practice environment of the covid-19 Pandemic, point’s nurses should consider as it relates to the Code of Ethics Bahamas

• Nurses should consider the Code of Ethics for nurses based on situations of crisis, including response to pandemics[33].
• Nurses must decide the level of quality care they can provide to their patients while taking care of themselves and their loved ones.
• Nurses should inquire about the expectations that hospitals, agencies, managers, administrators, institutions, and the health ministry requires of them during a pandemic.
• Registered nurses should or can make a choice based on moral ground as a premise for maintaining the professional integrity[34].
• Nurses should have the knowledge of their choice to volunteer during a pandemic based on factors such as if they qualify as a vulnerable group, they feel physically incapable of caring for patients, have inadequate support and are concerned about their legal, professional and ethical security in providing care during COVID-19[35].

Implications for Family Island Nurses: Improvements for Future Epidemic/Pandemics

Risk communication: risk communication is a type of communication that requires nurses to have a real-time exchange about outbreaks, advice, and opinion of experts and knowledge about the risks faced by those in the frontline defense against pandemics and epidemics[36]. Effective risk communication encompasses communication between the administration, experts, and healthcare agencies with the nurses. It includes response teams and authorities assigned during pandemics/epidemics[37].  The factors to consider include the type and content of the message, communication uncertainty from the administrators and experts, and establishing a feedback and listening system[38].

Technology: Nurses can be advised to use avenues such as social media and other technological tools to know what is happening at the moment. Such tools are ideal for monitoring, responding, and creating situational awareness among nurses[39].

Establish coordination and information systems: developing an organizational network among nurses in Family Island will provide the right platform based on geographic, disciplinary, and national boundaries on communication on situational awareness[40]. The premise is to help improve emergency risk communication that requires a substantial budget. The proposed budget could be a proposed USD $ 10 million for the first year, post-pandemic for training, and establishment of communication for nurses in the Family Islands. It may include setting up a committee that is tasked with recommending information systems to use for nurses, training on future protocols in sharing information, including experts, health ministry, and health professionals. The emergency risk communication is crucial to providing a strategic plan for future emergency preparedness and response among nurses in Family Island.

Healthcare Planning Checklist for COVID 19/Any Other Related Pandemic In The Future

Table 1: A Healthcare Planning Checklist for COVID 19/Any Other Related Pandemic In The Future

Staffing For Family Island Nurses in Pandemic Crisis to Ensure Adequate Care

The following need to be considered during staffing in the Family Islands in a pandemic crisis:  Comprehension of the staffing needs alongside the minimum number of nurses required to provide adequate care. The environment and patient to nurse ration need to be considered[44]. Communication should be established between local authorities and national authorities, including the Ministry of health on pandemic preparedness, including the need to hire more nurses, including volunteers, when needed. Aspects, including nurses’ availability regarding illnesses and capacity to work, should be addressed. They include illnesses, pregnancies, and at-risk populations. Considerations on the type of patients to be handled should also be considered. They encompass the type of patient care, degree of interaction between nurse and patient, and course taken regarding the Pandemic[45].

Preventing Healthcare Worker Infections

The recommended approaches can be made in two facets: vertical and horizontal. For vertical approaches, the objective is to reduce infections to specific pathogens. It includes active surveillance and testing of nurses for asymptomatic carriers, decolonization of patients who are infected with specific organisms, and contact precautions for patients with infections[46]. For the horizontal approach, the aim is to reduce the broad range of infection that is not pathogenic. The approach entails the standard operations in the hospitals (such as disinfection of hands), universal use of gloves and personal protective equipment, antimicrobial stewardship, and environmental cleaning and disinfection[47].

Keeping Healthcare Workers on the Front Lines Informed

Healthcare organizations should be at the forefront of providing information to nurses. Information includes distributing information on the role of nurses during Pandemic, preferred sources of treatment and testing guidance to use during the crisis[48]. Further, healthcare organizations should have unidirectional communication channels in which epidemiologists, doctors, and experts relay information to nurses. The objective is to reduce information overload where each expert is relaying information to the nurses[49]. Within the medical institutions, there should be a one-channel communication such as e-mail on the provision of information. The objective is to reduce misinformation and relay of information from both non-credible and unlicensed experts[50]. The need is to ensure that there is a synchronization of information to provide to the nurses during a pandemic.

Surveillance Unit-Family Islands

The recommended surveillance unit should be set-up within the Health Ministry in the Family Islands. The unit will be responsible for verification, detection, risk and severity assessment, and monitoring pandemic[51]. The unit can be supervised under a Ministry appointed medical director responsible for the roles and oversight of the unit. The Unit comprises experts, including epidemiologists, virologists, and health officials who are mandated to inform healthcare practitioners, including nurses, through direct communication during a pandemic.

Psychological support for Essential Workers

The following are the recommendations that healthcare organization should undertake during a pandemic crisis:

• Family Island staff should be protected from chronic stress, burnout, and poor mental health. In this process, designated psychologists should be available during staff shifts to cater to mental preparedness. Nurses should be made aware of where and how they can access mental health services[52].
• Healthcare organizations should institute protocols that evaluate nurses’ psychological well-being in the capacity to care for patients during a pandemic. A nurse who is not suited to work will not be allowed to handle patients.
• Family Island Hospitals should ensure that nurses are provided with adequate information that is accurate regarding the Pandemic[53].
• Partner experienced workers with non-experienced workers through a buddy system to improve care, monitor stress, and encourage work breaks.
• Urgent information or mental and neurological complaints should be addressed. They include psychosis, severe anxiety, and depression, among others[54].
• Family Island Hospitals should provide essential psychotropic medications at all levels accessible to the nurses.

Importance of Janitorial and Clerical and Other Support Staff Be Trained In High Cleaning

Janitors and clerical, as well as other support staff, need to be trained on high cleaning protocols and measures. Their importance cannot be over-emphasized. Therefore, training on basic knowledge regarding pathogens, including coronaviruses, their impact, and how cleaning services are important should be conducted[55]. Training should be done on a yearly basis considered as a refresher training program for the Family Island cleaning personnel. The training will also include disinfecting, deep cleaning, and scrubbing surface protocols. The training should also encompass how to put on PPE and how to discard them[56].

Identify/construct negative pressure rooms on family islands in the event client needs to be nursed in such a setting

Negative pressure rooms are recommended for hospitals in Family Island. The recommendation is to contain airborne infection particles from spreading to other areas in the hospitals and the surroundings[57]. The rooms will require an isolation area with ventilators that filter the air before being released into the environment. It is essential for negative pressure rooms where the doors are air-tight to prevent other patients from interacting with other patients. The negative pressure recommendation should be below 5 pascals with ventilators filtering air at 50 cubic meters per minute[58].

Importance of having proper disposal for waste/sharps and laundry

Family Island hospitals should have designated stations for disposal of waste, biological waste, sharps, and laundry. Each waste and laundry type will be marked with different types of color bins. For instance, yellow bins will be for bio-hazardous waste, red will be for contagious waste, and green will be for recyclable material (15). The overall recommendation is for hospitals to have a coordinated disposal system whereby the nurses are trained along with the cleaning team on how to dispose of waste (15).

Training Nurses on the Family Islands in Swabbing Clients with Nasopharyngeal Swabs

Family Island nurses should be trained on how to carry out swabs on patients with nasopharyngeal swabs. There are protocols already established that nurses can be trained on, such as the World Health Organization protocol[59]. It includes the establishment of a separate room for swab sampling, which is a strategic management criterion in specimen collection during pandemics[60]. Training of nurses should be specific to the type of pandemics experienced, including COVID-19, SARS, MERS, and others. The new training regimen provided by WHO ensures that aerosol droplets produced during sneezing or coughing do not spread either through direct contact with the nurses or other patients[61].

Legal Considerations for Family Island Nurses When Dealing With a Pandemic

There are new legal considerations to undertake during a pandemic. Considerations include respiratory protection standards. Due to the incidence and epidemiology of COVID-19, nurses should be vigilant on employee rights regarding protection against the harmful environment with specific emphasis on personal protective equipment. It should be mandatory for nurses to be provided with PPE during a pandemic to avoid infection[62].

Home Visits and protection of the at-risk population during Pandemic

Nurses should be trained on how to handle home visits, especially considering at-risk patients. Protocol recommendations would include training nurses on what to do during home visits. For instance, nurses should always wear PPE before entering a residence[63]. Additionally, they should know what further measures and action call to take if they encounter an at-risk patient since transporting them to the hospital may endanger them more.

Identifying Community Partners/Stakeholders on the Family Islands to assist in Pandemic

The recommended partners or stakeholders are healthcare institutions, educational centers, local governments, national governments, and community organizations. There should be a nation-wide law policy regarding the role each should play during a pandemic[64]. For instance, educational institutions can provide volunteers, including nurses and psychologists, during a pandemic.

Supplies and Equipment Needed

Medical supplies could include PPE, ventilators, extracorporeal membrane oxygenation (ECMO), disinfectant, and consumables[65].

Coordinated Communication with Nurse In charges during pandemics through technology

A proposed Information Technology system needs to be implemented across all hospitals in the Family Islands. The objective is to create a coordinated system in which nurses in charge can communicate with each other. For each hospital, the nurses will have a stand-alone network that allows them to communicate directly with their supervising nurse[66]. The communication software can be linked to their mobile phones, which reduces the costs of implementing the software.

Importance of having a listing of all NCD’s, Asthmatics, Heart, antenatal, Renal and Cancer patients, elderly, at-risk population

For the nurses, the goal is to reduce the number of deaths during an epidemic or Pandemic. The essential component of achieving this is through the identification of populations that can be affected during the crisis and match these populations with the resources available[67]. The proposition is to create a database in each hospital that outline the vulnerable populations based on the previous epidemics and pandemics such as asthmatics, chronic lung disease, kidney failures, NCD’s, the elderly in hospice or nursing homes.  The information provides a detailed action plan to take regarding each population and based on the severity of the crisis[68].

Supporting Patient Health through Telehealth Technologies

Telehealth technologies encompass the use of internet-based electronics from computers to mobile phone devices. For Family Island nurses, telehealth should be available in all the islands permitting access to available patient information, communication with nurses-in-charge, and support management of healthcare[69]. The recommendation is to incorporate a patient portal that contains at-risk patient population, patient information, up-to-date communication on a crisis, management toolkits, and allow nurses to have remote monitoring of patients from each hospital[70].

Importance of Proper Construction of Clinics on the Family Islands

For Family Island clinics, it is paramount to re-structure, re-design, and re-plan the clinics’ designs. It should include intensive care units, acute care units and HVAC loads, detailed floor plans, and electrical equipment[71]. The importance is to prepare the facilities to contain patients during a pandemic or epidemic in the future. The rule of thumb is that the reconstruction project should not cost more than 1.5 of the overall budget and revenue of hospital income[72].

Importance of Portable Handwashing Stations

During a crisis, Family Island frontline responders should have access to handwashing stations to minimize the spread of pathogens (22). Having portable handwashing stations will make it easier for nurses to access them without having to look for them. Ideally, they can be used off-site regardless of the crisis, which allows nurses and associated hospital staff to adhere to personal hygiene standards (22).

Identify Emergency Response Team from Members of the Community

The identification of the emergency response team is dependent on the crisis and the extent (projected) crisis. They include volunteer services for hospitals, emergency service units, and off-site members who can aid nurses in providing primary care to patients (22). Additionally, it includes services such as food, water, shelter, and clothing services for the afflicted. Educational institutions, churches, boarding houses, hotels, and motels can serve as emergency response team volunteers who are crucial to housing more patients if hospitals are overwhelmed (22).

Airlift/transport of patients (protection of pilots and support staff)

Maintenance of essential services, including air transport, is a toolkit provision required by the national government or local governments. Airlifts are crucial to transportation during an epidemic that requires immediate medical assistance, and going through normal channels is unavailable. A plan provided under local governments in coordination with the national government should be provided to roll-out when needed[73].

Transportation of Specimens

The recommendation is to have a general 72-hour period for the transportation of specimens. More than the time limit means the specimens are invalid. Collection sample toolkits and specific transportation vessels should be designated and given high priority during a pandemic or epidemic[74]. Coordinated efforts from all the Family Islands should be placed with at least two centers designated for accepting the specimens.

Funeral home to be Identified Protocols

Management of dead bodies is crucial during a pandemic as it is crucial to reducing infection rates. Local governments should have a clear protocol on identification procedures involving family members, the process of accepting the body, and the burial permit. Logistics of identification should be given to local mortuaries who will have specific recommendations on how to go about burials[75].

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