- Open Access
Fundamental nursing care in patients with the SARS-CoV-2 virus: results from the ‘COVID-NURSE’ mixed methods survey into nurses’ experiences of missed care and barriers to care
BMC Nursing volume 20, Article number: 215 (2021)
Patient experience of nursing care is associated with safety, care quality, treatment outcomes, costs and service use. Effective nursing care includes meeting patients’ fundamental physical, relational and psychosocial needs, which may be compromised by the challenges of SARS-CoV-2. No evidence-based nursing guidelines exist for patients with SARS-CoV-2. We report work to develop such a guideline. Our aim was to identify views and experiences of nursing staff on necessary nursing care for inpatients with SARS-CoV-2 (not invasively ventilated) that is omitted or delayed (missed care) and any barriers to this care.
We conducted an online mixed methods survey structured according to the Fundamentals of Care Framework. We recruited a convenience sample of UK-based nursing staff who had nursed inpatients with SARS-CoV-2 not invasively ventilated. We asked respondents to rate how well they were able to meet the needs of SARS-CoV-2 patients, compared to non-SARS-CoV-2 patients, in 15 care categories; select from a list of barriers to care; and describe examples of missed care and barriers to care. We analysed quantitative data descriptively and qualitative data using Framework Analysis, integrating data in side-by-side comparison tables.
Of 1062 respondents, the majority rated mobility, talking and listening, non-verbal communication, communicating with significant others, and emotional wellbeing as worse for patients with SARS-CoV-2. Eight barriers were ranked within the top five in at least one of the three care areas. These were (in rank order): wearing Personal Protective Equipment, the severity of patients’ conditions, inability to take items in and out of isolation rooms without donning and doffing Personal Protective Equipment, lack of time to spend with patients, lack of presence from specialised services e.g. physiotherapists, lack of knowledge about SARS-CoV-2, insufficient stock, and reluctance to spend time with patients for fear of catching SARS-CoV-2.
Our respondents identified nursing care areas likely to be missed for patients with SARS-CoV-2, and barriers to delivering care. We are currently evaluating a guideline of nursing strategies to address these barriers, which are unlikely to be exclusive to this pandemic or the environments represented by our respondents. Our results should, therefore, be incorporated into global pandemic planning.
Patient experience of care is associated with safety, clinical effectiveness, care quality, treatment outcomes, costs and service use [1,2,3,4,5], and nursing care is a key determinant of this experience [6, 7]. Although nurses perform both generalist and specialist roles, all nurses are involved in meeting patients’ ‘fundamental’ care needs. Defining fundamental care has in the past been a contested area , but there is now greater consensus  in that fundamental care can be described as ‘actions on the part of the nurse that respect and focus on a person’s essential needs to ensure their physical and psychosocial wellbeing’ ( , p.2292). These needs are met by developing a positive and trusting relationship with the person being cared for as well as their family/carers . Therefore, the discrete elements of fundamental care can be described as: actions to meet patients’ physical needs, and their psychosocial (wellbeing and mental health) needs; these actions include nurses’ transactional and relational behaviours .
The combination of SARS-CoV-2 symptoms and infectiousness of the SARS-CoV-2 virus may pose significant challenges for meeting patients’ physical and psychosocial needs, as well as impacting on nurses’ relational and transactional care behaviours. Such challenges may result in ‘missed care’ or ‘care left undone’, defined as any aspect of nursing care that is omitted or delayed, in part or in whole [11, 12]. Whilst our current study focuses specifically on fundamental nursing care, missed care can therefore include areas of fundamental nursing care (e.g. meeting patients’ hygiene needs) as well as other areas of nursing care (e.g. discharge planning) . Prior to the SARS-CoV-2 pandemic, both nurses and patients indicated that important elements of fundamental nursing care are regularly missed, including nutrition, hygiene (e.g. bathing; mouth care), ambulation/ supporting mobility, communication/ talking with patients, and emotional and psychological support [13,14,15,16,17]. The extent of missed care is related to poor patient outcomes, increased mortality and adverse events, and poor patient satisfaction and experience of care [15, 18,19,20]. Factors contributing to missed care include high patient to registered nurse ratios, associated lack of nurse time, patient dependency/ acuity, and the practice environment (e.g. managerial support) [12, 16, 17, 21], and the likely impact of the SARS-CoV-2 pandemic on all of these factors may further increase incidences of missed care. Indeed, we know from nurses’ narrative accounts of the Canadian SARS outbreak in 2003 that Personal Protective Equipment (PPE) , time pressures  and visitor restrictions  can lead to patients feeling abandoned by nurses .
Given the short time since the SARS-CoV-2 virus first emerged in late 2019, knowledge of its impact on nursing care has been slow to emerge and as yet there is no direct data on patients’ experience of nursing care. Most of the research published to date has focussed on the impact on nurses’ wellbeing, not on their processes of caring. Thus, we know from surveys conducted in China and Italy that front-line nurses have experienced huge workload; long-term fatigue; infection threat; and anxieties and frustration concerning the death of patients for whom they cared. Additionally, they worried about their families and vice versa . A survey completed by 764 nurses (60.8%) and 493 physicians (39.2%) from 34 hospitals in China reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]) amongst the health care workers. Nurses, frontline health care workers, female health care workers, and those working in Wuhan, reported more severe mental health symptoms than other health care workers . Nurses in Italy reported Post-Traumatic Stress Disorder symptoms, severe depression, anxiety, insomnia and perceived stress , and UK nurses were concerned about the risks of SARS-CoV-2 on their physical and mental health, as well as the health of their families [28, 29].
There is evidence emerging from the UK that these effects on nurses, together with the rapid adjustment of healthcare systems to accommodate the pressures of increased patient flow, redeployment of inexperienced staff into isolation care environments, and other factors, may have had a negative impact on patients. One survey on recovered patients’ experiences at discharge found that 82% of respondents had not received post-discharge assessment visits, and 18% reported having unmet needs . Thus, the negative impact of the SARS-CoV-2 outbreak on nurses may in turn impact patients, acting as a mediator of missed care. However, we do not currently know if the concerns raised in the brief reports from the Canadian SARS outbreak have been replicated or learnt from in this current pandemic, and there are currently no evidence-based guidelines for nursing patients with SARS-CoV-2 who may be receiving ventilatory support without tracheal intubation (i.e. not invasively ventilated), who represent the majority of hospitalised patients with this condition. This leaves nurses without guidance and is potentially associated with variations in patient experience, care quality and costs as redeployed and/or inexperienced nurses struggle to adapt to caring for patients in strict isolation  using unfamiliar care procedures required for infection prevention and control .
We designed the COVID-NURSE cluster randomised controlled trial  to evaluate a fundamental nursing care protocol for patients hospitalised with the SARS-CoV-2 virus not invasively ventilated. The fundamental nursing care protocol has been developed from three main areas of activity: i) a survey of registered nurses’ and non-registered auxiliary nursing/ healthcare support workers and assistants’ views and experiences of caring for patients with SARS-CoV-2 including the barriers encountered in delivering fundamental care and strategies adopted to overcome these; ii) a rapid systematic review of the literature ; and iii) four co-creation workshops involving nurses and patients with experience of being hospitalised with the SARS-CoV-2 virus not invasively ventilated, in which the findings from the survey and the systematic review were presented and discussed.
In this paper, we report the findings from the survey of nurses that relate to their views and experiences of missed fundamental care and barriers to fundamental care for inpatients with SARS-CoV-2 not invasively ventilated. We will report findings on strategies used to overcome the barriers to care in a future article, to avoid potential contamination of the trial before completion.
Aim and design
Our aim was to identify the views and experiences of registered nurses and non-registered nursing care staff on missed fundamental care and the barriers to fundamental care for inpatients with the SARS-CoV-2 virus not invasively ventilated. We conducted a cross-sectional study employing a mixed methods explanatory design  guided by a pragmatic philosophy . For the quantitative and qualitative components, we collected data concurrently and analysed data sequentially (with qualitative data analysed in order to explain the quantitative data). We gave the quantitative component greater priority as this guided our analysis of qualitative data, and we mixed the components during data analysis. This approach enabled us to utilise the qualitative data to elaborate on, clarify, illustrate and contextualise the key quantitative findings [37, 38].
Participants and recruitment
Eligible respondents were UK-based registered nurses and non-registered auxiliary nursing/ healthcare support workers/ assistants that had actively engaged in nursing inpatients with the SARS-CoV-2 virus who were not invasively ventilated. Thus, respondents who had nursed patients who were not ventilated, or patients who received non-invasive ventilation, were eligible; respondents who only nursed invasively ventilated patients were ineligible. We invited a convenience sample of respondents using a range of strategies; including a database of nurses who had consented to be approached for SARS-CoV-2 related research studies through their involvement in the ‘Impact of COVID-19 on the Nursing and midwifery workforce’ (ICON) study ; networks of senior research, management and clinical nurses in England and Wales including contacts within the National Institute for Health Research (NIHR) 70@70 research network, the Association of UK Lead Research Nurses, the Royal Colleges, and hospital sites affiliated with the COVID-NURSE Trial co-investigators; the UK NIHR Clinical Research Network; and through social media including Twitter and University of Exeter channels. We aimed for our survey distribution channels to be as inclusive as possible in terms of encouraging responses from nurses working in different types of hospitals, including general vs. specialist, which were geographically diverse and serving populations of different ethnicities.
We sent a link to the survey to nurses on our database and to key gatekeepers in the networks listed above. We asked gatekeepers to circulate the link via newsletters, emails and other communication channels appropriate to their networks with a covering letter informing potential respondents of the purpose and timeframe for the survey. The landing page for the survey provided links to the participant information sheet, frequently asked questions, and the survey. As this was an exploratory study to guide our intervention development, within the specific time limits of the COVID-NURSE trial and thus using a convenience sampling frame, we did not have a predetermined sample size calculation and sought to recruit as many respondents as possible during the timeframe of the survey.
Data collection and materials
The survey was open for 3 weeks, plus 3 days to respondents who had commenced the survey, to provide the opportunity to complete it. We developed the survey with input from the COVID-NURSE trial Co-Investigators and members of the wider research team, in response to formal and informal feedback from four nursing teams who piloted the survey, and in line with comments from the University of Exeter Medical School Ethics Committee. At all times in the development of the survey we involved members of our patient and public involvement group (PPI) including our PPI co-investigators and trial management group member, who gave us advice on the survey design. Using Qualtrics™ online survey software , we designed a bespoke online series of survey questions including demographic items. We structured our survey according to the Fundamentals of Care model [8, 9]. We included three sections on physical, relational and psychosocial areas of care, and subsections in each of these areas corresponding to sub-categories of care as adapted from Feo et al. (2018)  (Table 1).
In each subsection (Table 1), we asked respondents to:
Rate how well they thought they were able to meet the needs of patients with the SARS-CoV-2 virus (excluding those who had been invasively ventilated) compared to their ability to meet the needs of other patients they were experienced in nursing before SARS-CoV-2. For example, for section one (physical care), subsection one, respondents were asked to rate how well they were able to meet the hygiene, personal cleansing and toileting needs of patients with the SARS-CoV-2 virus (excluding those who had been invasively ventilated) compared to their ability to meet the hygiene, personal cleansing and toileting needs of other patients they were experienced in nursing before SARS-CoV-2. Respondents were asked to provide answers on a five point Likert-type scale with the following options: much better than, a little bit better than, the same as, a bit worse than, or much worse than. Alternatively, respondents could indicate that they were not involved in this area of care;
Provide free text to narratively identify and describe examples of missed fundamental care;
Select all relevant barriers to fundamental care from a list provided. The barrier list was derived from discussions with the COVID-NURSE trial Co-Investigators with expertise in nursing. Barriers were standardised across all sub-categories, with additional barriers added where relevant for a specific category. A list of barriers available for each sub-category is provided in Additional file 1;
Provide free text to narratively identify and describe examples of barriers to fundamental care.
The UK Clinical Research Collaboration (UKCRC)-registered University of Exeter Clinical Trials Unit received, cleaned and processed the data, and uploaded datasets to Microsoft Excel . We applied pairwise deletion to each survey item in order to maximise the data available, and reported all percentages as the percentage of the total number of respondents who provided data for that survey item. We combined ethnicity data into standard categories .
Quantitative data analysis
We analysed quantitative data, including demographic data, descriptively. For respondents’ ratings of care, we combined responses into four categories for ease of interpretation: 1) better than other patients (combining ‘much better’ and ‘a little bit better’); 2) the same as other patients; 3) worse than other patients (combining ‘much worse’ and ‘a bit worse’); 4) not involved in this area of care. For both ratings of care and barriers to care, we calculated the frequency, and percentage, of respondents selecting each option for each sub-category of care. We also calculated the percentage of respondents selecting each barrier in total across each of the three care areas (physical; relational; psychosocial).
Qualitative and mixed methods data analysis
We achieved familiarisation with the data through reading survey responses and analysed data using Framework Analysis  to allow for both inductive and deductive approaches in combining our study aims/ survey questions with participants’ original accounts [42, 43]. In undertaking qualitative analysis within our explanatory mixed methods design, we focused on explaining the key quantitative findings rather than completing a full, independent analysis of qualitative themes, so that we could understand respondents’ meanings in providing their quantitative responses and focus in on qualitative examples in key problem areas indicated by the quantitative data.
Data interpretation and the development of analytic categories were discussed by a multidisciplinary team trained in qualitative data analysis and consisting of five researchers (HVRS, A-MR, HI-S, DAR, NM) with backgrounds in nursing (3), nursing education (3), mental health services research (2) and clinical research (2). The team was led by HVRS; A-MR, HI-S, NM and HVRS independently coded subsets of the raw data; HVRS double-coded and verified subsets of the data coded by A-MR, HI-S and NM.
For missed care and barriers, we separately coded responses into a framework structured according to the Fundamentals of Care Framework. Within each sub-category of care, we analysed survey responses thematically using a constant comparison approach, and examined similarities and differences in respondents’ accounts in order to categorise the examples of missed care and barriers for each sub-category [44, 45]. For barriers to care, we then focused our analysis on the main barriers highlighted by the quantitative data, categorising the qualitative findings across all sub-categories of care into each of the top five rated barriers for each of the three care areas (physical; relational; psychosocial). We have integrated the quantitative and qualitative data in side-by-side comparison tables  organised by the quantitative data (for missed care, from highest to lowest percentage of respondents rating the sub-category of care as ‘worse’; for barriers to care, from highest to lowest percentage of respondents selecting the barrier). In these tables we have included summaries of the qualitative findings and quotes to illuminate these.
From 3rd to 26th August 2020, 1062 eligible respondents consented to provide survey data; 84 of these provided no further data. The number of respondents providing data for each survey item is provided in Additional file 1. Respondent characteristics are summarised in Table 2.
Respondents’ views on missed fundamental care
The percentage of respondents rating the physical, relational and psychosocial care of patients with the SARS-CoV-2 as worse, the same as, or better than other patients, for each constituent sub-category of care, is shown in Figs. 1, 2 and 3. Frequencies are provided in Additional file 1.
For sub-categories of care across all three care areas (physical, relational, psychosocial), a majority of respondents rated their ability to meet the needs of SARS-CoV-2 patients as worse than for other patients. The following sub-categories were rated as worse by a majority of respondents: ‘talking and listening’ (57%); ‘communicating with relatives, carers and significant others’ (57%); ‘mobility’ (56%); ‘non-verbal communication’ (54%); ‘emotional wellbeing, anxiety and depression’ (53%). Just less than half (49%) of respondents also rated ‘establishing a relationship with patients’ as worse for SARS-CoV-2 patients. For all the other physical sub-categories (aside from ‘mobility’), approximately one third or less of respondents rated care as worse for SARS-CoV-2 patients (range 26–34%). For relational care, almost one third of respondents (32%) rated ‘shared decision-making’ as worse for SARS-CoV-2 patients, and for psychosocial care ‘dignity and respect’ and ‘respecting patients’ values and beliefs’ were rated as worse for SARS-CoV-2 patients by 26 and 19% of respondents respectively.
Integrated quantitative and qualitative results
In Tables 3, 4 and 5 we have presented side-by-side comparison tables integrating the quantitative findings and summarised qualitative findings on missed care for each sub-category of physical, relational and psychosocial care. Respondents’ ID numbers are included in brackets after quotes.
Between 26 and 56% of respondents struggled to meet all sub-categories of patients’ physical needs efficiently and effectively compared to patients they would normally care for. Particularly highlighted were restrictions on patients’ mobilisation outside of side (isolation) rooms, and some respondents also described issues with interrupted sleep; missed and delayed personal care, particularly mouth care; restrictions and delays in providing food and drink; reductions in observing patients in side rooms; errors and potential for errors, particularly around medications; challenges with controlling symptoms of breathlessness and high temperature; missed pressure area care; and a lack of presence from multidisciplinary colleagues such as physiotherapists, dieticians and pharmacists.
In relational care, the majority of respondents (57%) highlighted communication difficulties with patients and their significant others, with almost half of respondents reporting that this impacted on their ability to establish a relationship with patients. Respondents struggled to build rapport with patients; experienced restrictions in being heard, understood, and spending time with patients; and were less able to use facial expressions, non-verbal cues and touch to comfort patients. Respondents reported that patients missed having visits from significant others, and they struggled to both keep significant others informed and obtain information about patients from them. A third of respondents also experienced shared decision-making as more rushed and policy-led than usual.
In psychosocial care, the majority of respondents (53%) reported struggling to support patients’ emotional wellbeing and mental health, typically prioritising functional and physical care over emotional care. Most respondents were unable to provide usual levels of support, reassurance and interaction with patients, and reported that patients experienced isolation, loneliness, fear and low mood. A minority of respondents also had difficulties maintaining patients’ privacy and dignity, such as drawing curtains for personal care or distressing scenes; lacked knowledge about patients’ beliefs; and noted a lack of presence from psychological services and chaplaincy.
Respondents’ views on barriers to fundamental care
We summarise the percentage of respondents selecting each barrier in Table 6 (presented as the average percentage of respondents selecting the barrier, and the range of respondent percentages, across the constituent sub-categories of physical, relational and psychosocial care; where the barrier was only an option for one sub-category, we just present the percentage of respondents selecting the barrier for that sub-category). We have listed barriers in the order of most to least frequently selected across all care areas. We have provided the number of respondents selecting each barrier for each sub-category of care in Additional file 1.
In total, eight barriers were ranked within the top five in at least one of the three care areas (Tables 7, 8 and 9). ‘Wearing PPE’, and the ‘severity of the patient’s condition’ were the most frequently selected barriers and were among the top five barriers to all three care areas. The third most frequently selected barrier, ‘difficulties taking items/ equipment in and out of isolation rooms’, was among the top five barriers to physical care. ‘Lack of time’, the fourth most frequently selected barrier, was among the top five barriers to both psychosocial and relational care. ‘Lack of personnel, skill mix, catering, housekeeping or dietetic support’, the fifth most frequently selected barrier, was among the top five barriers to both physical and psychosocial care. The sixth most frequently selected barrier, ‘lack of knowledge about COVID-19’, was among the top five barriers to both relational and psychosocial care. The seventh most frequently selected barrier, ‘not enough physical resources such as equipment/ washing facilities/ stock items’, was the final top five barrier to physical care. The eighth most frequently selected barrier, ‘fear of catching COVID-19’, was the final top five barrier to relational care.
Integrated quantitative and qualitative results
In Tables 7, 8 and 9 we report the top five barriers per care area in order of highest to lowest percentage of respondents selecting this barrier across the constituent sub-categories. We also include the sub-category for which the highest percentage of respondents selected the barrier in that care area, and then integrate the qualitative data in side-by-side comparison tables. Respondents’ ID numbers are included in brackets after quotes.
Respondents struggled to meet the physical care needs (particularly rest and sleep, mobility, eating/drinking, and personal care) of patients who were very unwell, often attached to oxygen equipment, and with high monitoring requirements. Wearing PPE also created a physical barrier to meeting such needs, particularly hygiene needs. A lack of storage and stock supplies in SARS-CoV-2 areas, and the increased need to clean items between uses, meant insufficient supplies for respondents to meet patients’ needs and make them comfortable. The need to don and doff PPE upon entering and leaving a patient’s room delayed responding to patients’ needs, meant staff had to try to prepare all items needed in the room before entering, and created difficulties providing patients with items such as food and drinks. Respondents also experienced staff shortages and a lack of presence from specialised services which increased their own workloads, and compromised patients’ care and safety.
Wearing PPE created a very significant barrier to relational care and communicating with patients, compromising hearing, lip reading, seeing facial expressions, use of non-verbal cues and touch. PPE also made staff difficult to recognise. Due to staff shortages and high patient acuity, respondents had little time to spend talking and listening to patients, prioritising a functional approach to care. This was compounded by respondents’ reluctance to spend time in patients’ rooms due to fear of catching SARS-CoV-2, which limited their ability to establish a relationship with patients. Patients’ ability to communicate and participate in decision-making was also compromised by the severity of their own conditions, and respondents felt they lacked the knowledge of SARS-CoV-2 required to answer patients’ questions during the decision-making process in particular. Running through these accounts was the impact of restrictions on visitors, for both patients’ wellbeing and staff’s ability to communicate with significant others, particularly in the context of a lack of time to update significant others remotely and consult on time critical decision-making.
Respondents experienced similar barriers to psychosocial care as to relational care, including the impact of restrictions on visitors. Patients’ wellbeing and staffs’ ability to create therapeutic relationships suffered as a result of the barriers to communication presented by PPE. Again, staff had limited time to spend supporting patients’ emotional and spiritual needs; patients’ abilities to communicate their needs and beliefs were compromised by the severity of their conditions; and staff found it difficult to answer patients’ questions about SARS-CoV-2 or provide them with reassurance. The lack of SARS-CoV-2 knowledge also caused fear and anxiety for patients. Respondents experienced a lack of presence from psychology services and chaplaincy which limited support for patients, and some lacked the expertise to support patients’ psychological needs.
In this survey, we found that respondents rated their ability to meet patients’ needs in many areas of fundamental care as worse for hospitalised patients with SARS-CoV-2 than for other patients they were experienced in caring for before the pandemic. Although meeting patients’ needs was rated by some respondents as worse in all areas of care; the majority of respondents specifically identified mobility; talking and listening; non-verbal communication; communicating with relatives, carers and significant others; and caring for patients’ emotional wellbeing, anxiety and depression as poorer. Across the categories of physical, relational and psychosocial care, we found the strongest reports of difficulties were with undertaking relational care, with the majority of respondents rating their ability to meet patients’ needs as worse in three of the five categories. In contrast, although 26–34% of respondents rated elements of physical care as worse, it was only for mobility that the majority (56%) cited deficits in this care area specifically. For psychosocial care, most respondents thought that their ability to meet patients’ needs was at least as good or better in the areas of respect, dignity, values and beliefs but this contrasts with more than half reporting that their ability to address patients’ emotional wellbeing, depression and anxiety needs was poorer.
Respondents identified clear reasons why they thought these elements of care were worse for these patients. Foremost was infection control, specifically the wearing of PPE and nursing patients in isolation. PPE was cited as a barrier to relational care by twice as many respondents as any other barrier. It was uncomfortable for respondents, created a barrier to providing physical care, and impeded verbal and non-verbal communication. Insufficient stock, and staffs’ inability to take items in and out of isolation rooms without donning and doffing PPE, were also significant barriers to physical care. These barriers were compounded by the severity of the patient’s condition, requiring as it did the use of oxygen equipment, proning (nursing patients in the prone position), and causing patients’ difficulties in communicating when breathless and/or sedated. Another top five barrier to physical and psychosocial care was the lack of presence from specialist services, and a lack of expertise in redeployed staff themselves. Time, or the lack of it, prevented respondents from talking and listening to patients, although another highly cited barrier was staffs’ own reluctance to spend time with patients for fear of catching SARS-CoV-2 themselves. This was compounded by a lack of knowledge about SARS-CoV-2 which impeded respondents’ ability to answer patients’ questions. Throughout their accounts, respondents noted the impact of restrictions on visitors for both patients and nursing staff. This series of barriers conspired to mean that nurses largely focused on the functional, physical aspects of care, with relationship-building and addressing patients’ emotional wellbeing becoming a secondary priority.
Our results support previous work in related areas. With previous studies suggesting that fundamental nursing care is already regularly missed in the areas of mobility, communication and talking with patients, and providing emotional and psychological support [13,14,15,16,17], our findings highlight the further impact of the SARS-CoV-2 virus on meeting patients’ needs in these particular areas. Consistent with previous explanations for missed care prior to the pandemic [12, 16, 17, 21], respondents highlighted patient acuity and lack of time as barriers to meeting patients’ needs, amongst other challenges more specific to the pandemic context.
Respondents’ accounts of the impact of wearing PPE on communication and the development of therapeutic relationships with patients, and the impact of restrictions on visitors for patients’ emotional wellbeing at a time when nurses themselves struggled to meet these needs due to time pressures and PPE, reflect nurses’ non-empirical accounts of the Canadian SARS outbreak in 2003 [22,23,24]. Our findings concur with nurses’ reports of high workloads and their fears regarding the risks posed by SARS-CoV-2 to themselves [25, 28, 29]. Respondents’ accounts regarding the impact of these factors are consistent with the reports of patients themselves, who may experience poor communication, a lack of support and assistance, and insufficient information and/or equipment . In addition, relatives, carers and significant others can experience poor communication from hospital staff and may not be kept well informed about the patient . Indeed, our findings regarding respondents’ lack of knowledge about SARS-CoV-2 for providing patients with information, the barriers they report to communication with both patients and their significant others, and the lack of supplies reported may help to explain such experiences.
Strengths and limitations
A key strength of this study is that it is the first to focus on fundamental nursing care in the context of SARS-CoV-2. Despite the relationship between fundamental nursing care, patient experience, treatment outcomes and costs, investigation into fundamental nursing care in the heavily compromised environment of SARS-CoV-2 is not an objective of current SARS-CoV-2 research programmes. Prior to this study we lacked knowledge as to the specific impact of the SARS-CoV-2 virus on meeting patients’ fundamental physical, relational and psychosocial needs.
A further strength is our use of a mixed methods explanatory design. By collecting and integrating quantitative and qualitative data, we have produced a more comprehensive, in-depth and insightful portrait of the issues under investigation [35, 36, 47, 48]. To enhance the usefulness of our results for informing a future nursing protocol, we have used our qualitative findings to explain, illustrate and contextualise our quantitative findings, with a pragmatic focus on understanding the key issues which our nursing protocol needs to address [36,37,38]. However, it is possible that full, independent thematic analysis of the qualitative data may have highlighted different aspects of the data and presented the data in a different light.
A potential limitation of this study is the absence of a predefined sample size. We employed a convenience sampling frame with a sample size determined by the period of time the survey was open for, which was in turn constrained by the rapid nature of the wider COVID-NURSE trial and the need to gather pandemic evidence as quickly as possible in a rapidly evolving situation. We also experienced respondent fatigue whereby the number of respondents providing data generally reduced as they worked through the survey items . However, we were not seeking to generalise our findings beyond the sampled population via inferential statistical methods which would have formed the basis of any sample size calculation . Furthermore, in all qualitative items we did reach data saturation, at which point data from additional respondents was no longer providing additional clarity or insight; thus, our sample size could be considered adequate as well as appropriate (as our eligibility criteria ensured respondents were experts in the area of interest) [51, 52].
It may have been beneficial to include Allied Health Professionals (AHPs) within our sample; however, time constraints and timelines for additional ethical approvals were prohibitive. The inclusion of AHPs may have provided additional insights, particularly in relation to our finding that a lack of presence from AHPs was considered a barrier to fundamental care by respondents. In addition, given the proportions of different staff completing the survey, our results largely represent the views of registered nurses rather than non-registered members of the nursing workforce who may have held differing views or offered additional insights.
Implications and future research
Whilst our findings concur with non-empirical reports from previous pandemics [22,23,24], to our knowledge this study is the first to quantify nurses’ own views as to the impact of a highly infectious virus on their work, and to combine this with qualitative insights to help explain why specific elements of fundamental care are affected. As such, it provides clear guidance for educators, clinicians, managers and policy makers on what to expect and prepare for in caring for patients in pandemic situations.
Further research should build on these findings, addressing the following remaining questions: what is the impact of nurses’ self-reports of missed fundamental care on missed fundamental care as experienced by patients?; what are the implications on patient safety issues such as reduced mobility, infection, and malnutrition, which are often related to missed fundamental care?; what strategies can be incorporated in nursing care to reduce the frequency and impact of missed fundamental care? In our case, we have used these findings together with further information from our systematic review, and from nurses and patients themselves on strategies to confront the barriers to fundamental care identified in this study, to devise a guideline and nursing protocol for pandemic situations. We are currently testing this protocol in a cluster randomised controlled trial .
Although our data were collected from a specific nursing context – inpatient care for patients with the SARS-CoV-2 virus who were not invasively ventilated – we suggest that our results have the potential for generalising to other care environments and other pandemic situations globally. Most of the concerns and barriers identified by our respondents are not specific to the SARS-COV-2 virus, nor their particular nursing environment. Communication is at the heart of all good nursing care globally, as it establishes the platform for compassionate and collaborative transactional care which addresses patients’ physical and psychosocial needs [8, 9]. Intrinsic too is the organisation of care and inter-professional working, as well as nursing education about the epidemiology of illnesses and on specific techniques to be used. All these areas are not exclusive to the current SARS-CoV-2 pandemic and we suggest, therefore, that our results will be useful for others devising strategies to support nursing care in other environments (such as care homes), other countries and for other pandemics.
In a survey of nurses caring for patients in hospital with the SARS-COV-2 virus not invasively ventilated, the majority of respondents rated their ability to meet the needs of these patients as worse than for patients they normally care for in five of 15 specific fundamental care areas. These areas included one physical, three relational and one psychosocial nursing care area, highlighting that communication with patients and their significant others was the major and consistent concern for nurses, alongside organising care (especially mobilisation) for patients nursed in isolation, and addressing patients’ emotional wellbeing and mental health. The major barriers to fundamental care were the wearing of PPE, the severity of these patients’ conditions, lack of time, difficulties taking items and equipment in and out of isolation rooms, lack of interdisciplinary input, lack of knowledge about SARS-CoV-2, and fears of catching the illness itself. The difficulties faced by nurses in establishing relationships with patients led to concerns that care became merely functional and not individualised or patient-centred. These concerns are unlikely to be specific to the SARS-CoV-2 pandemic nor the hospital environments represented by our survey respondents. These results should, therefore, be incorporated into subsequent global pandemic planning by nursing leaders.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Applied Research Collaboration
Allied Health Professionals
Coronavirus disease 2019
Continuous Positive Airway Pressure
Do Not Attempt Resuscitation
Impact of COVID-19 on the Nursing and midwifery workforce
Medical Research Council
National Institute of Health Research
National Health Service
Applied Research Collaboration South West Peninsula
Personal Protective Equipment
Patient and Public Involvement
Royal College of Nursing
Severe acute respiratory syndrome coronavirus 2
Strengthening The Reporting of OBservational studies in Epidemiology
United Kingdom Clinical Research Collaboration
Darzi A. Quality and the NHS next stage review. Lancet. 2008;371(9624):1563–4. https://doi.org/10.1016/S0140-6736(08)60672-8.
Vincent C, Amalberti R. Safer healthcare: strategies for the real world. Cham: Springer Nature; 2016. https://doi.org/10.1007/978-3-319-25559-0.
Black N, Varaganum M, Hutchings A. Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery. BMJ Quality Safety. 2014;23(7):534–42. https://doi.org/10.1136/bmjqs-2013-002707.
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). https://doi.org/10.1136/bmjopen-2012-001570.
Department of Health. Report of the mid Staffordshire NHS Foundation trust public enquiry. London: Department of Health; 2013.
Graham C, Käsbauer S, Cooper R, King J, Sizmur S, Jenkinson C, et al. An evaluation of a near real-time survey for improving patients’ experiences of the relational aspects of care: a mixed-methods evaluation. Health Serv Delivery Res. 2018;6(15). https://doi.org/10.3310/hsdr06150.
Murrells T, Robert G, Adams M, Morrow E, Maben J. Measuring relational aspects of hospital care in England with the ‘patient evaluation of emotional care during hospitalisation’ (PEECH) survey questionnaire. BMJ Open. 2013;3(1). https://doi.org/10.1136/bmjopen-2012-002211.
Kitson A, Conroy T, Wengstrom Y, Profetto-McGrath J, Robertson-Malt S. Scholarly paper: defining the fundamentals of care. Int J Nurs Pract. 2010;16(4):423–34. https://doi.org/10.1111/j.1440-172X.2010.01861.x.
Feo R, Conroy T, Jangland E, Muntlin Athlin Å, Brovall M, Parr J, et al. Towards a standardised definition for fundamental care: a modified Delphi study. J Clin Nurs. 2018;27(11-12):2285–99. https://doi.org/10.1111/jocn.14247.
International Learning Collaborative. The Fundamentals of Care 2019. Available from: https://intlearningcollab.org/mission/the-fundamentals-of-care/#physical. Accessed 8 Dec 2020.
Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509–17. https://doi.org/10.1111/j.1365-2648.2009.05027.x.
Ausserhofer D, Zander B, Busse R, Schubert M, De Geest S, Rafferty AM, et al. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Quality Safety. 2014;23(2):126–35. https://doi.org/10.1136/bmjqs-2013-002318.
Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006;21(4):306–13. https://doi.org/10.1097/00001786-200610000-00006.
Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. JONA: J Nurs Admin. 2009;39(5):211–9. https://doi.org/10.1097/NNA.0b013e3181a23cf5.
Kalisch BJ, Xie B, Dabney BW. Patient-reported missed nursing care correlated with adverse events. Am J Med Qual. 2014;29(5):415–22. https://doi.org/10.1177/1062860613501715.
Griffiths P, Recio-Saucedo A, Dall'Ora C, Briggs J, Maruotti A, Meredith P, et al. The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs. 2018;74(7):1474–87. https://doi.org/10.1111/jan.13564.
Ball JE, Griffiths P, Rafferty AM, Lindqvist R, Murrells T, Tishelman C. A cross-sectional study of ‘care left undone’on nursing shifts in hospitals. J Adv Nurs. 2016;72(9):2086–97. https://doi.org/10.1111/jan.12976.
Bruyneel L, Li B, Ausserhofer D, Lesaffre E, Dumitrescu I, Smith HL, et al. Organization of hospital nursing, provision of nursing care, and patient experiences with care in Europe. Med Care Res Rev. 2015;72(6):643–64. https://doi.org/10.1177/1077558715589188.
Recio-Saucedo A, Dall'Ora C, Maruotti A, Ball J, Briggs J, Meredith P, et al. What impact does nursing care left undone have on patient outcomes? Review of the literature. J Clin Nurs. 2018;27(11–12):2248–59. https://doi.org/10.1111/jocn.14058.
Ball JE, Bruyneel L, Aiken LH, Sermeus W, Sloane DM, Rafferty AM, et al. Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. Int J Nurs Stud. 2018;78:10–5. https://doi.org/10.1016/j.ijnurstu.2017.08.004.
Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. ‘Care left undone’during nursing shifts: associations with workload and perceived quality of care. BMJ Quality Safety. 2014;23(2):116–25. https://doi.org/10.1136/bmjqs-2012-001767.
Canadian Nurses Association. CNA brief to the National Advisory Committee on SARS and public health: lessons learned and recommendations. Ottawa: Canadian Nurses Association; 2003.
Registered Nurses Association of Ontario. SARS Unmasked: Celebrating Resilience, Exposing Vulnerability. A Report on the Nursing Experience with SARS in Ontario. Toronto: Registered Nurses Association of Ontario; 2003.
Baumann A, Blythe J, Underwood J, Dzuiba J. Capacity, casualization, and continuity: the impact of SARS. Toronto: University of Toronto, Faculty of Nursing and McMaster University, School of Nursing; 2003.
Shen X, Zou X, Zhong X, Yan J, Li L. Psychological stress of ICU nurses in the time of COVID-19. Crit Care. 2020;24(200). https://doi.org/10.1186/s13054-020-02926-2.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open. 2020;3(3):e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976.
Rossi R, Socci V, Pacitti F, Di Lorenzo G, Di Marco A, Siracusano A, et al. Mental health outcomes among front and second line health workers associated with the COVID-19 pandemic in Italy. medRxiv. 2020. https://doi.org/10.1101/2020.04.16.20067801.
Kelly D. Researching the impact of COVID-19 2020. Available from: https://www.rcn.org.uk/magazines/bulletin/2020/june/icon-research-nursing-study-professor-kelly-covid-19. Accessed 8 Dec 2020.
Thorley P. Survey of UK nurses and midwives’ highlights their concerns about health, training and workload during COVID-19 [press release]; 2020.
Healthwatch. 590 people’s stories of leaving hospital during COVID-19 2020. Available from: https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20201026%20Peoples%20experiences%20of%20leaving%20hospital%20during%20COVID-19_0.pdf. Accessed 8 Dec 2020.
Gammon J, Hunt J. A review of isolation practices and procedures in healthcare settings. Br J Nurs. 2018;27(3):137–40. https://doi.org/10.12968/bjon.2018.27.3.137.
World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016.
University of Exeter. COVID-NURSE: The development, testing and evaluation of a COVID-19 fundamental nursing care protocol: a randomised controlled trial 2020. Available from: http://blogs.exeter.ac.uk/covid-nurse/. Accessed 8 Dec 2020.
Coon JT, Whear R, Abbott R, Bethel A, Cockcroft E, Cooper J, et al. Effectiveness of and barriers to fundamental nursing care procedures in patients with SARS-COV-2 virus: a rapid systematic review. PROSPERO 2020 CRD42020200914. 2020. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200914.
Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks: Sage; 2007.
Borglin G. The value of mixed methods for researching complex interventions. In: Richards DA, Hallberg IR, editors. Complex interventions in health: an overview of research methods. Oxon: Routledge; 2015. p. 29–45.
Greene JC, Caracelli VJ, Graham WF. Toward a conceptual framework for mixed-method evaluation designs. Educ Eval Policy Anal. 1989;11(3):255–74. https://doi.org/10.3102/01623737011003255.
Bryman A. Integrating quantitative and qualitative research: how is it done? Qual Res. 2006;6(1):97–113. https://doi.org/10.1177/1468794106058877.
Qualtrics (Producer). Qualtrics Survey Software. 2020.
Office. Excel undated. Available from: https://products.office.com/en-gb/excel. Accessed 13 Mar 2017.
Office for National Statistics. Research report on population estimates by ethnic group and religion 2019. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/researchreportonpopulationestimatesbyethnicgroupandreligion/2019-12-04. Accessed 8 December 2020.
Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: a guide for social science students and researchers. 2nd ed. Los Angeles: Sage; 2013.
Pope C, Mays N. Qualitative research in health care. 3rd ed. Oxford: Blackwell Publishing; 2006. https://doi.org/10.1002/9780470750841.
Miles MB, Huberman AM, Saldana J. Qualitative data analysis: a methods sourcebook. 3rd ed. Los Angeles: Sage; 2014.
Thorne S. Data analysis in qualitative research. Evid Based Nurs. 2000;3(3):68–70. https://doi.org/10.1136/ebn.3.3.68.
Knottnerus A, Tugwell P. STROBE--a checklist to strengthen the reporting of Observational studies in epidemiology. J Clin Epidemiol. 2008;61(4):323. https://doi.org/10.1016/j.jclinepi.2007.11.006.
Wisdom JP, Cavaleri MA, Onwuegbuzie AJ, Green CA. Methodological reporting in qualitative, quantitative, and mixed methods health services research articles. Health Serv Res. 2012;47(2):721–45. https://doi.org/10.1111/j.1475-6773.2011.01344.x.
O'Cathain A, Murphy E, Nicholl J. Why, and how, mixed methods research is undertaken in health services research in England: a mixed methods study. BMC Health Serv Res. 2007;7(1):85. https://doi.org/10.1186/1472-6963-7-85.
Lavrakas PJ. Encyclopedia of survey research methods. Thousand Oaks: Sage Publications; 2008. Available from:. https://doi.org/10.4135/9781412963947.
Bartlett J, Kotrlik J, Higgins C. Organizational research: determining appropriate sample size in survey research. Inf Technol Learn Perform J. 2001;19(1):43–50.
Morse JM. The significance of saturation. Thousand Oaks: Sage; 1995.
Morse JM. Data were saturated. Qual Health Res. 2015;25(5):587–8. https://doi.org/10.1177/1049732315576699.
We thank the respondents in this study and the other members of the COVID-NURSE team for their support: Joanne Cooper; Claire Hulme; Nigel Reed; G. J Melendez-Torres; Harry Tripp; Stephen Wootton.
This work is supported by the NIHR and UK Research and Innovation, administered by the MRC: grant number MR/V02776X/1. The Trial Sponsor is the University of Exeter, ref.: 1920/ Research Ethics and Governance Office, Lafrowda House, St Germans Road, Exeter, Devon, EX4 6TL. The work is also supported by the NIHR Applied Research Collaboration South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The sponsor and funding sources have had no role in the design of this study, nor during the collection, analysis, and interpretation of data, nor in writing this manuscript.
Ethics approval and consent to participate
This study was granted ethical approval by the University of Exeter Medical School Ethics Committee (Application Number Jul20/D/256) and Health Research Authority research and development governance assurance (IRAS reference 287288). Informed consent to participate in the study was obtained electronically from participants at the beginning of the survey. All methods were performed in accordance with the relevant guidelines and regulations including the Declaration of Helsinki.
Consent for publication
Informed consent to publish anonymised participant data was obtained electronically from participants at the beginning of the survey.
AMRa is President of the Royal College of Nursing. All other authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Sugg, H.V.R., Russell, AM., Morgan, L.M. et al. Fundamental nursing care in patients with the SARS-CoV-2 virus: results from the ‘COVID-NURSE’ mixed methods survey into nurses’ experiences of missed care and barriers to care. BMC Nurs 20, 215 (2021). https://doi.org/10.1186/s12912-021-00746-5
- Fundamental nursing care
- Missed care
- Mixed methods