perception and barriers of intensive care init nurses in comprehensive care during covid 19 pandemic in hanoi medical university hospital vietnam

The barriers of nurses performing Comprehensive care in Intensive care unit during the COVID-19 pandemic.... The barriers of nurses performing comprehensive care in the ICU during the CO

HANOI MEDICAL UNIVERSITY

PHANI THI DUNG

PERCEPTION AND BARRIERS OF INTENSIVE CARE UNIT NURSES IN COMPREIlENSIVE Care during

COVTD-19 PANDEMIC IN HANOI MEDICAL UNIVERSITY HOSPITAL VIETNAM

GRADUATION THESISBACHELOR OF SCIENCE IN NURSING

Advanced Program in Nursing

2016-2021

Supervisor Assoc Plot Hoang Bui Hai M.D, Ph D

Mai Thi Hue MPH

Hanoi 2021

AC K NOWLEDG EM E NT

I would like to express my deepest gratitude to my supervisor Assoc.Prof Hoang Bui Hal M.D Ph.D and Mrs Mai Thi Hue MPH for the excellent guidance, caring, patience and providing with tlie tremendous support during this research

I am also grateful to all lecturers m the Institute of Intensive care and Emergency department, Hanoi Medical University for their comments, helps and supports

I would like to express my sincere thanks to all hospital staff in Intensive CaieUnit at Hanoi Medical University Hospital for their facilitation

in data collection process

I place on my record, my sincere gratitude to all members in the research team for sharing expertise, valuable support and encouragement extended to me

Hanoi May 5’b 2021Thesis author

Pham T1Ũ Dung

I hereby declarethat this thesis is composed by myself, which has not been previously submitted, either in a pan or in full, for a degree to any other institution or university As far as 1 know, material has been previously published or written by other persons are not contained in my thesis except where reference has been shown in the text

Hanoi May 5* 2021Thesis author

Pham Thi Dung

CONTENTS ••••• ••• ••••••••

• •••• • ••••••••••a \

vm

ix

IN 1 kODƯCTĨON •••••• ■« 1

•• • • • • ’ • • • •M CHAPTER 1: LITERATURE REVIEW ••• •••• 1.1 Comprehensive care model 3

1.11 Comprehensive care definition 3 1.12 Comprehensive care and the COVID-19 pandemic 3

1.12.1 Overview of the COVID-19 pundemi c 3

1.12.2 The situation of comprehensive care before the c OVID-19 pandemic - 5

1.12.3 The situation of comprehensive care during the COVID-19 pandemic 8

1.2 The nursing role in comprehensive care 9

1.3 The barriers of nurses in comprehensive cares - 10

1.4 Comprehensive care in ICƯ, Vietnam 11

CHAPTER 2: SUBJECTS AND METHOD - 13

2.1 study time & setting 13

2.2 Study participants 13

2.3 Studydesign- - 13

2.4 Study instruments 14

The trustworthiness of a qualitative research

2.8.1 Credibility of this study _

15161820202.82 Dependability of Ulis study • • !•

2.83 Transferability of this study

22223.1 General cliaracteristics of participants

3.2 The barriers of nurses performing Comprehensive care in Intensive

care unit during the COVID-19 pandemic 253.2.1 Banners related to insufficiency of human resource 263.22 Barner related to ovet whelmed and stressed by the nursingworkload — 293.23 Barrier rdated to the unprofessional structure of the ICƯ353.2.4 Barrier related to non-cooperation of tile patient’s relatives 373.23 Barner related to the uncertainty and anxiety of being infected COVID-19 and infecting others - 383.3 The perception of nurses about comprehensive care in the ICƯ

during COVID-19 pandemic • ••••••••••••••••••••••••••••••••••••••••••••••••••• 413.3.1 The participant's perspective about the future nursingcare model ’ •• • •- •••••• •• •••••••••••••••••••••• ••••••«••••••«• •••••« «• • •• «• • •• •••«•••» 41

4.1 General characteristic of stud}’ 46

4.2 The barriers of nurses performing comprehensive care in the ICU during the COVID-19 pandemic 48

4.2.1 Ranier related IO insufficiency of human resource 49

4.22 Barrier related to overwhelmed and stressed by the nursing workload 50 4.23 Barrier related to the unprofessional structure ofthe ICU51 4.2.4 Barrier related to non-cooperation of the patient's relatives 52

4.23 Barrier related to the uncertainty and anxiety of being infected with COVID-19 and infecting others 53

4.3 The perception of nurses about comprehensive care in the ICƯ during the COVID-19 pandemic 54

4.3.1 The participant's perspective about the future nursing care model .H 34

4.32 The expected factors that should be available to achieve comprehensive care in the future 55

4.4 Limitation Of this study 56

4 5 The research proposal

CONCLUSION

RECOMMENDATION 59

REFERENCES 1

APPENDIX

LIST OF TABLESTable 2 1 The stud}- parameters - 15Table 3 1 Participants' demographic information 22Table 3.2 Characteristics of the study participant 24Table 3 3 Main themes reflecting the barriers of nurses performing Conxpt ehens ive care in ICC’ during COVID-19 pandemic.- 26Table 3.4 Barrier related to insufficiency of human resource — 27•Table 3 5 Barner related to overwhelmed and exhausted by the nursing workload — 30Table 3.6 Barrier related to the unprofessional structure of the ICC 35Table 3 " Barner related to non-cooperation of the patient’s relatives 37Table 3 8 Barrier related to the uncertainty and anxiety of being infected COVID-19 and infecting others — 39Table 3.9 The participant's perspective about the future nursing care modcl41Table 3 10 The expected factors that should be available to achieve comprehensive care in tile future 43

Table 3 11 Human resources factor that should be available to achieve comprehensive care in the fixture 43Table 3 12 Medical materials factor that should be available to achieve comprehensive care in the future 44

LIST OF FIGI RES

Figure 2 1 The process of Qualitative data collection - 17Figure 2.2 The Qualitative research process - 19

LIST OE ABBREVIATIONS

COVID-19 Coronavirus disease 2019

ICƯ Intensive care unit

HXflJH Hanoi Medical University HospitalWHO World Health Organization

has been widely developed in many parts of the world to meet the increasing demand of patients Its principles are based on the combination of both the clinical treatment and non-treatmenT aspects which include personal hygiene, daily diets and mental care [ 1 ].

While this model of care has been fundamentally well-established in high-income countries such as the United States, the United Kingdom Australia, and the Netherlands [2J [3 J [4] [5] it is quite a vague concept ill many resources' constraint countries Particular^ in Vietnam, the implementation of comprehensive care has only been constricted to highly standardized, private hospitals: and most public hospitals have been absent or incomplete of this healthcare model In fact, several nursing cares associated

to non- treatment aspects have been realized by patient's relatives

ỉn 2013 and 20 Id Nutan Potdai el al performed studies in the Intensive care unit (ICV) of Krishna hospital India regarding multiple barriers experienced by nurses and doctors when providing comprehensive care for patients They revealed that increased workload, less equipment and lack of human resources were major baniers for medical staffs [6] [7]

The complex progression of the coronanius disease 2019 (COVID-19) pandemic has catastrophically been a global health care burden In addition, nursing care lias consequently changed to adapt to tins new situation To accommodate the Vietnamese nurses in the 1CU have fluff ly practiced

“comprehensive care" that consisted of unacccpting the assistance of the patient's relatives as a dedicated model for COVID-19 care

ỉ Tơ describe barriers of nurses in comprehensive care during the COi 'ID-19 pandemics in the Intensive Care I nil at Hanoi Medical

I nrversity Hospital, I ietnam from October to Nos ember 2020.

2 Jo understand these nurses' perspectives uhout comprehensive care during the C0Ĩ1D-19 pandemics in theIntensive Care I’nlt at Hanoi Medical University Hospital, Vietnam from October to November 2020.

CHAPTER 1: LITERATURE REVIEW

1.1 Comprehensive care model

1.1.1 Comprehensive care definition

Comprehensive care is an advanced healthcare model worldwide tliat has been widely acknowledged as the best way forward to achieve the integral healthcare demand of multimortid patients [1Ị [8], [9] [10], [11] [12] In addition, comprehensive care can be defined as active initiatives seeking to structure and coordinate care and improve health outcomes while limiting health care expenditures [IJ Many different terms are being applied for comprehensive care consisting of integrated care, care according to guidelines, cases and general care management Moreover, the models are considered comprehensive if they meet several of the health care needs of people with multiple chronic illnesses, functional disabilities, and/or high levels of health care utilization and if the health care services are provided by numerous HCWs [12] Multiple theories have been proposed to "patient- centred cure" as a comprehensive care criterion [ 10) [ 11 ] [ 12]

Its principles are based on the combination of both the clinical treatment and non-treatment aspects which include personal hygiene, daily diets, and mental care Thus, comprehensive health care is alwajs considered

as an essential part of every health facility as a mean to pranote treatment outcomes o f pat rent s [ 1 ]

1.12 Comp reh enũve care and the co VII) 19 pandemic

1.12.1 Overview of the COliD-19 pandemic

According to World Health Organization (WHO) the COVTD-19 is an infectious disease caused by a newly discovered corcnavirus It has ưiggered off a worldwide pandemic of a respiratory illness that was first identified in December 2019 in Wuhan City in China [13Ị

This novel coronavirus is stnrcturaly associated with the virus that causes severe acute respiratory syndrome (SaRS) Tins has also been explored in prior studies that these symptoms of COVID-19 can range from a mild cold to moderate diseases, even life-threatening In addition, fever, cough, and fatigue are the most common symptoms at the onset of COVID-19 illness while other symptoms include sputum production, headache, haemoptysis, diarrhoea, dyspnoea, aid lymphopenia [14], [15], [16], [17] Moreover, previous studies have emphasized that person-to-person transmission is a primary infectious pathway for COV1D-19 [17] [18] The spreading occurs primarily via direct contact or through diopiets by coughing

or sneezing from an infected individual The critical solution to prevent and slow transmission is to have a proper perception of the COVID-19 virus, the disease it causes, and how it spreads Protect yourself and others from infection by washing your hands or using alcohol-based detergents frequently and not touching your face as suggested by' WHO [19], Additionally, mamtannng a distance of at least I meter between yourself and others is also the best way to reduce the risk of infection when they cough, sneeze or speak Maintain greater distance between yourself and others when indoors Make wearing a mask normal part of being around Ollier people The appropnate use storage, and cleaning or disposal are essential to make masks as effective

as possible

Ou top of that, a large number of recent studies have recognized tlrat COVID-19 is the latest threat to global health is the ongoing outbreak of respiratory disease Indeed, it lias affected nearly every region of the work! and by March 6 2021, there have been 115 289 961confirmed cases worldwide with the deaths of more than 2 564 000 people; 2 4SS confirmed

eases and 35 deaths have been reported in mainland Vietnam and as known as having clusters of cases of transmission classification [19],

Therefore, health- care workers (HCWs) have played a vital role in every country Their health and safety are crucial not only for continued and safe patient care but also for controlling any outbreaks [20] However, health care providers during a severe COV1D-19 outbreak have been under extraordinary stress and barriers associated with a high risk of infection, stigma, lack of staff, and uncertainty For instance, the follow ing studies were conducted on HCWs’ experiences Front-line medical staff who take care of patients with COVID-19 are al increased risk for mental health problems, such as anxiety, depression, insomnia, and stress [21] Frontline doctors and nurses with no expertise in this infectious disease face additional challenges

as they adapt to a completely new work environment in these stressfill situations This has also been explored in prior studies 111 2020 by Yicen Yan and his colleagues, insufficient and excessive protection will have adverse effects on the skin and mucous membrane of healthcare workers [22]

J.U.2 Dre situation of comprthaaive care before the COHD-19

pandemic

By enhancing the quality and continuity of care, comprehensive care aims improve patient health outcomes, while at the same time creating efficient use of healthcare resources

There have been numerous studies to investigate overview of comprehensive care programs pfTfornrd for patients with multiple chronic diseases indicated that evidence of their effects on patients and caregivers is inconsistent [12], [23], [24] [25], [26] [27], [28] In most of these reviews, the criteria for inclusion in the studies were rather narrow in multiple countries Studies axe considered to be of high quality if they meet five

criteria: design's strength (review meta-analysis or controlled trials with the equivalent concurrent control groups) adequacy of tile sample (representative sufficient number), the validity of measures, rd lability' of data analysis techniques, and rigor of data analysis.

Some reviews LU general consist of randomized controlled trials [12], [24], [26], while others only evaluated the impact of programs on patient outcomes [12], [26] [27] [28] or included studies showing positive effects of comprehensive care programs that have shown tire potential to refine quality, efficacy, or health-related outcomes of care for patients were identified [12], Furthermore, most reviews provide limited information aboui the content of the comprehensive care program Therefore, relevant information from the non-randomized trials and information on the impact programs have on caregiver outcomes is barely summarized

Besides there were inconsistent results of comprehensive care in multiple countries, each country also had mixed effectiveness In 2015 an

"evidence check” rapid review brokered by the Sax Institute for the Australian Commission on Safety' regarding the best available research evidence for the effectiveness of comprehensive care in acute settings as defined By providing an iterative, systematic, step-by-step approach to gain insight into the characteristics and effectiveness of these new comprehensive care programs for patients, they emphasized that tile new comprehensive care standard will incorporate the following three elements: systems to support care: development of comprehensive care plans: delivery of comprehensive care and quality in health care In addition, they found 16 articles, of which regarding tlieir effects, the results were mixed and consisted of 12 (75%) were

of moderate to high methodological quality, thr ee (18.75%) were of moderate

qualty and one (6.25%) was of low quality All were relevant for and generalizable to lite Australian acute care settings and populations [29].

Additionally, little is known about program features tliat may be relevant to positive outcomes of care and about the groups of patients who may benefit most from comprehensive caie For instance, the effectiveness of comprehensive care was comparable or more positive than that of ordinary care This has also been explored in a prior systematic study in multiple electronic databases for English language papers published between January

1995 and January 2011 by De Bruin and his colleagues [1] dial die profitable effects of comprehensive care on inpatient health care utilization Besides, evidence is also found for the positive effects of comprehensive care on patient health behaviour perceived quality of care, and satisfaction of patients and caregivers Insufficient evidence lias been found for the profitable effects

of comprehensive care on quality of life related to mental health, outpatient healthcare utilization, medication use and healthcare costs No evidence was found fox the profitable effects of comprehensive care oil cognitive function, depressive symptoms, fiinctionai status, mortality, quality of life on physical function, and caregiver burden

Despite the fact tliat several (good quality) studies have been performed ovex the years to estimate the value of comprehensive care for multi modal and or frail patients, there is insufficient evidence for the efficacy' of which More good-quality studies and oi studies that enable mcta-analysis are needed

to determine which particular target groups will benefit from comprehensive care Furtlierniore evaluation studies can be improved by utilizing more appropriate outcome measures, for example measures related to care goals defined by patients (individuals)

However this information is critical because of growing interest in what will help the best care for patients with multi morbidity especially in the ICU which supports and improves patients’ health with multimodal and/or frail.

A number of questions regaldmg the effectiveness of comprehensive care in JCU remain to be addressed Rarely public research in this area IS performed not only in Vietnam but also in over the world Instead of that, it was developing knowledge in specific units such as the endocrinology unit [2 J mental health unit [3] gerontology unit [12] [23J et Unfortunately, tliese mentioned studies are not available for Vietnam Therefore, evaluating and improving rhe quality of care and the urgency of implementing a new- comprehensive model at ICƯ in Vietnam is a difficult challenge

J.U.3 The situation of comprehensive care during the COỈ1D-Ỉ9

pandemic

The COVID-19 was declared with a rapid global outbreak Unfortunately, a large proportion of infected patients need admission and comprehensive management, however the knowledge about the effectiveness

of comprehensive care as well as barriers of medical staff accomplishing this model on those patients have been generally limited, especially in ICƯ

While it is clear tliat incomprchensive care could weaken treatment efforts in every health facility, this issue is far worse in the ICU including in Vietnam

w hen ÚMC COMD-19 outbreaks occur As nurses are now- in the context of COVID-19 pandemics, the medical staff cannot depend on patients* relatives fot non-treatment supports

In Vietnam, the consequence of the COVID-19 pandemic has led to a demand for the medical staff that has to adopt a new concept of patient care Particularly, ICU in several central Vietnamese hospitals, including Hanoi

Medical University Hospital (HMƯH) to designate comprehensive cate as a dedicated unit for COV1D-19 care, which fulfils care accomplished based on the significance of patient safety without the support of patients' relatives.1.2 The nursing role in comprehendve care

Nunes play a crucial role in the evaluation and implementation of comprehensive cate which contributes a lot to the panent healing process Nurses not only maintain the patient safety and decrease mortality but also pros ide extensive quality sen ices to reach their satisfaction Even though there are competent physicians present in die institution It would not be adequate when deficiencies the appropriate nursing care Nurses have 24-hour contact with patients as well as near to them, so they are seen like the frontline Accordingly, the patients have the orientation to expect more from them and nurses should also respond to patient's needs with competence and compassionate access If tire patient is denied appropriate care tile treatment process is obviously compromised on this path assessing barriers and critical care units while providing nursing care is vital to identify the obstacles to the nurses in their wort: environment and to improve rhe nursing services at rhe sanr time

Furthermore, in the c OVID-19 stages, die duty of nursing is increasingly on a remarkable point Each patient has various characteristics and manifestations that require nurses to maintain critical thinking and make decisions properly

Moreover, working in a completely new context to prevent the spreading of coronavirus that made nurses prov ide the accmate and promptly care for multiple patients including patient with COVID-19; suspected patient; non COVID-19 patient

1.3 The barriers of nurses In comprehensive cares

As we have known since care has an effect on cultutal economic and social factors, tliere are diverse bamers in the realization of care Especially in Asian countries, family traditions are maintained and highly respected, they assume one of tile ancient conceptions that the sick bosjxtahze all trust and empower their relatives for no- treatment care Therefore, fora long time, the patient's family members occupy a significant position in the treatment process as well as improve the patient's mental health They play a vital role

in helping patients with basic needs: observe and report the patient’s condition, personal hygiene, feeding, roil over, urine monitor, make a warm compress when the patient get fever, mobility support, mental support In addition, relatives will not be secure when we are not directly involved in taking care of and observing the paiient Because of that idea, health workers, including nurses, have uncompleted the sufficient function, especially in the noirtreatmenl care: basic personal needs, daily diets, and mental care Insufficient care has a strong relationship with the quality of caje,

Furthermore, most problems related to not completing a task arise from reasons: available supporter resources from the patient's relative: the serious lack of staffing and workload [30], A recent study in 2Ơ1Ó by Nuran Pordar and his colleagues assessed the barriers perceived by medical staff to comprehensive nursing care in ICU of Krishna Hospital Karad The result of

it shows tlwt tile correlation between stresses that are faced by docton and nurses during working are significantly associated with the barrier to comprehensive care in ICC In addition, it concluded tliat increased workloads, less equipment, and supplies in diverse attitudes among colleagues, and fewer staff-patient ratios are major barriers for doctors and nurses (7]

Besides, healthcare providers are critical resources for patient health improvement iliat cannot be ignored Tlieii health and safely ate crucial not only for continuous and safe patient care, but also for control of any outbreak However, health-care providers caring for patients during the severe acute respiratory syndrome (SARS)and Middle East respiratoiy syndrome (MERS) outbreaks were under extraordinary’ stress related to high risk of infection, stigmatisation, understating, and uncertainty, and comprehensive support

w as a high priority during the outbreaks and afterwards

Quantitative studies have shown that frontline healthcare providers Heating patients with COVID-19 have greater risks of mental health problems, such as anxiety, depression, insomnia, and stress [21] Frontline doctors and muses with no expertise in this infectious disease face additional challenges as they adapt to a completely new work environment in these stressful situations

To our knowledge, no qualitative studies of the barriers of these healthcare providers have been published performing comprehensive caie during the COXTD-19 pandemic To assess the effectiveness of comprehensive care to them, it is necessary to gain insights into their experience and the bar riers they have met

Ỉ.4 Comprehensive care ỉn lev Vietnam

To respond, the Ministry of Health issued Decision No 123QD-K2DT

in 2013 aimed at promoting comprehensive care in Vietnam Accordingly, continuous training materials and programs would be available for healthcan? staff to update knowledge, skills, and promote altitudes towards comprehensive care [31 ] Unfortunately, the implementation of comprehensive care has only been constricted to highly standardized, private hospitals; and most state hospitals have been absent or incomplete of this healthcare model

Nurses’ daily tasks in Vietnam are in nature heavily* involved in clinical treatment with little focus oil non-treatment aspects.

The complex progression of the coronavirus disease (COVID-19) pandemic in Vietnam and the consequent demand to adapt inpatient care provided to this health emergency led ICU in a few central Vietnamese hospitals, including Hanoi Medical University Hospital (HMUH) to designate comprehensive care as a dedicated unit for tire COVID-19 care, winch fillfils care accomplished based on tire significance of patient satisfaction without the support of patients' relatives

In lire primary response to COVID-19 crisis in Vietnam the ICU at HMUH has strived to separate illness inpatients from their relatives who have

a high risk of the COVID-19 crisis from the public as much as possible This implementation is to minimize the ability of inpatients to get COVID-19 from tile community Tile subsequent challenge was smooth operation with the new and unstandardized model while coping with human resources shortage and work overwhelming

Although there are several studies on models of care designed to accomplish these goals, no consensus exists on which models can improve clinical outcomes in the ICU Such consent, when reached, may inform our ailing healthcare system reform efforts and helps to shape the services offered

by increasingly popular

CHAPTER 2: SUBJECTS AND METHOD

2.1 Study time & setting

The study was conducted in the 1CU at HNÍVH Vietnam from October

to November 2020

2.2 Study participants

We recruited all nurses working in the ICƯ at HMUH who were accomplishing comprehensive cane for patients during the COVID-19 pandemic

Jhchuian criteria:

• Nurses working in the ICV "-ere directly practicing in comprehensive care for patients

■ Out of vacation time and during the COVID-19 episode

" Nurses were willing to participate in

■ Nurses had the ability to implement an online interview through Zoom meetings

Exclusion criteria:

■ ICU nurse in an administrative position and head of ICƯ nurse

■ Nurses refused to participate in the study or online interview- through Zoom meetings

2.3 Study design

• A qualitative study wus performed to describe barriers of nurses in comprehensive care and understand these nurses’ perspectives on comprehensive cate during the COVID-19 pandemics III the ICƯ

• Data collection was by group interviews via the internet based on the Zoom meeting platform In which, using sound and image recording function of this software Then the raw data was transcribed from the audio data to textual data

• All audio recordings and transcripts were saved on a password­protected computer.

2.4 Study instruments

We used a semi-struemred questionnaứe (15 questions) to collect information regarding studs objectives The questionnaire was included three main sections: (1) General information (2) Barriers when providing comprehensive care for patients (3) Nurse’ perspectives about comprehensive care

(1) General information: nurses were asked to provide information regarding age gender, wot king position, years of experience, education levels (7 questions)

(2) Barriers when proriding comprehensive care for patients: nurses were

asked to provide their views and thoughts about what you do even' day to lata? care of your patients before COVID-19 jwndemics? What do you do even day to take care of your patients currattly when COVID-19 occurs? What are the differences between before and after COV1D-19 pandemics in tbe nay of caring for patients? What difficulties that you have been facniH to take care of the patients during COXTD-19 pandemics? What kind of support

do you receive during COVID-19 TO be able to fulfill your current need of care? (5 questions)

(3) Perceptions about comprehensive care: What is the idea of nursing care

should be in the future? What do you think about die feasibility of integrating standardized comprehensive cate protocols in your department? What factors.' conditions/ ingredients should be available to achieve comprehensive care? (3 questions)

Besides, another study tool was Zootn meetings Software and all participants had a computer or smartphone that can enroll the online interview through zoom meetings.

2.5 Study parameters

Table 2 I The study parameters

AS Years of experienceA6 forking positionBarriers of

comprehensive care

Bl Routine nursing activities before the COVID 19

pandemicB2 Routine nursing activities during the COVID -19

pandemic

b ; The difference nursing care between before and

during the COVID-19 pandemicB4 Barriers of nursing perform comprehensive care

during the COVID -19 pandemicB5 Kind of supports the 1CU nurses have received

during the COVID -19 pandemicPerception of

comprehensive care

Cl Ibc lev nurses’ perspective about the future

nursing care modelC2 The feasibility of integrating a standardized

comprehensive care protocolC3 The expected factors should be available to

achieve comprehensive care

2.6 Data collection

- Data was collected through group interviews via an online software called Zoom meeting In which this study used sound and image recording function of this software during the interview time

“ All of the participants were randomly divided into two subgroups that were consistent with two interviews

- In the interview implementation, after introducing the study purposes, the nurse was invited to lake pan in the study All online interviews were conducted in a private room to make sure a comfortable environment and confidentiality Interviewers were first to warm up the conversation with greetings The interview heavily, but not merely, depends on afore-constructed questions The interviewers based on emerging ideas, information from nurses’ responses to ask additional questions to shape a full picture of the research objectives Data collection was continued until tlx? researchers were confident that no more new ideas, concepts, and categories emerged

- After the interview, we obtained two audio and video recordings The next step of the data collection procedure was to transcribe the raw data from audio data to text data In addition, confidentiality was assured by using numbers instead of names (eg Nurse 1 Nurse 2, etc) and removing identifying information from the transcripts

Concluding!?, the researcher had text data to facilitate data analysis

Choose the data collection method

Group Interview

Plan Ihrdala collection procedure

Sampling: 311ICLJ nurses at HMUH divided two random groups

Location: in online software (Zoom meeting) 2 times

rime: November 5 and November 6 2021

Study ifutrumetu a semi- structured questionnaire (15 questions)

Management data: using sound and image recording function via Zoom meeting

Implement the Interview

Follow up the data collection procedure

Transcript the audio data

Transcript from original audio data via Zoom meeting

Has ing available text data for anahsls

Figure 2 1 rhe process of Qualitative data collection

2.7 I>atA Analysis

All raw data was recorded and precisely transcribed Using Excel software; the data was synthesized and interpreted by applying a content analysis strategy

First of the data analysis process, the researcher read all the transcript several times to gain an understanding of meanings conveyed, identifying significant phrases and restating them in general terms, formulating meanings and validating meanings

Second, labeling of codes was conducted using the words of panidpams and perceived concepts of the text Similar codes were placed in one category that called ’ meaning unit" and fomted the categorization of codes The categories with similar concepts were located around a common and core axis

Then, categories with similar concepts and similar subjects were merged into

"sub-theme" Summarizing various sub-themes indicated "a specific theme ■

to develop a full description of study objectives

Designing and accomplishing

2.S The trustworthiness of a qualitative research

Trustworthiness or rigor of a qualitative study refers to the degree of confidence in data, interpretation and methods utilized to ensure the quality

of study

2.8.1 Credibility of this study

The data and processes of analysis address the intended focus on nurses' experience about the implementation of comprehensive care, particularly the barriers and perception of them in ICƯ at HMLH in the context of the cox ID-19 pandemic Besides, choosing the focus group interview allows for the exchange of ideas, opinions, and viewpoints that might nor be revealed through surveys or interviews, which helps researchers better understand the topic at hand Furthermore, one of the crucial issues in the study method is select the most suitable meaning units The analysis included reading Ute transcript several times to perceive meanings conveyed, identify significant phiases and had the consult horn experts Moreover, all

of the categories and themes cover data were sincerely reveal by ICU nurses and they are completely responsible for all their speech associated with comprehensive care during the COVID-19 pandemic

Triangulation has been intimated as "the process of conoborating evidence from various individuals, data types, or data collection methods ’ In particular, data sources might be interviews, observation of this meeting (including nonverbal expressions of participants), information got from semi­structured questionnaires Triangulation can also mention the collection of information from multiple types of participants about the same phenomenon The efTect of tile triangulation method is to create a more holistic picture of tire phenomenon that are studying and to prevent over-reliance on a single method or data collection source

2.82 Iỉcpendab lit tv of rhh study

Dependability mentions the extent to which approximate findings would be obtained if tlie study were repeated However variability' should be expectant in qualitative studies The best strategy to assist the dependability of

a study is to guarantee tliat the method is described in sufficient detail so that

it can be reproduced by others and any restrictions discussed Triangulation of the methods will also improve the dependability of the results

2.83 Transferability of this study

Transferability' indicates bow well research results can be applied to other similar orgaiuzations Hie ability' of others to appreciate whether the findings are transferable depends on a detailed description of the study context, the selection of participants, and the results This is associated with a

’Thick description"

2.9 Ethical consideration

• The study' subjects were explained clearly about the purpose of the study before the telephone interview Tile questionnaires were given only when subjects agreed to participate The right to withdraw at any time was explained dearly’ to the participants

- The study tool was not invoked sensitive or intimate problems and did not affect the subject’s emotion

• Collected data was used for research The results of the study were proposed for improving the quality of nursing care, not for other purposes

- Participants’ information was kept secret All information and comments were encoded without rewaling names and personal information

CHAPTER 3: RESULT

3.1 General characteristics of participants

Overall 12 participants were enrolled in the sample Demographic chararteristics of all participants were detail shown in table 4.1 and table 4.2 The age of all ICU nurse in the ICƯ at HMUH ranged from 25 years old to 38 years old which were divided into 2 groups: 20-30 years old 31-40 years old and no one in the period of above 41 Among participants, two-thirds of the participants (8) were female and 4 were male There is a balanced ratio between married nurse and single nurse Furthermore the participants who had been reported to be college level was 1 and for other participants in bachelor's degree was II All of them had more than I-year of experience in the ICC’ Besides, about the job position, the}’ totally in particular had the analogous working as nurses, and no one was head of the nurse or nurse supervisor

Table 3 I Participants' demographic information

Educationlevel

Job position

Nurse 1 30 Female Single More than 2

years

Bachelor’s degree

Nurse

Nurse 2 29 Female Married More than 2

years

Bachelor’s degree

Nurse

Nurse 3 29 Female Married More than 2

years

Bachelor's degree

Nurse 5 29 Female Single More than 2

years

Bachelor's degree

Nurse

Nurse 6 31 Male Marred More than 2

years

Bachelor'sdegree

Nurse

Nurse 12 25 Female Single 1 -2 years Bachelor's

degree

Nurse

Table 3.2 Characteristics õf the study participant

Characteristics of (lie Study Participants

3.2 The barrier* of mine* performing Comprehensive eare in Intensive cart unit during the COVID-19 pandemic.

Analysis of the interview data led to identification of five main themes reflecting the ICV nurses’ barriers of Comprehensive care during COVID-19 pandemic (Table 3.1) Overall the participants expressed positive attitudes about nursing care among Comprehensive care and acknowledged the growth

of the professional model worldwide and integrity as an important element of professional ism and job satisfaction Otherwise, they believed there were significant barriers to the optimization and completion of ÚŨS model Although an anas* of individual, organizational and stressors from environment issues was discussed during the interviews the most frequent discussions revolved around organizational barriers (insufficiency of human resources; nursing workload: the unprofessional structure of the ICU) Because there was applied a novel model- Comprehensive care After years of experience in their particular medical field, nurse had to take care of patients wi!h a condition that is different from tliat seen in their daily practice

Table 3 3 Main themes reflecting the barriers of nurses performingComprehensive care in ICƯ during COVID-19 pandemic

1 Insufficiency of human resource

2 Overwhelmed and stressed by the nursingworkload

3 The unprofessional structure of the ICU

4 Non-cooperation of the patient’s relatives

5 The uncertainty and anxiety of being infected COVID-19 and infecting others

3.2.1 Barriers related to Insufficiency of human resource

The first category of themes "Barrier related to the insufficiency of human resource”, consisted of five sub-themes relating to the mismatch between the number of muse staff compared with the number of patients and the huge workload nurses had to implement during the COVID-19 pandemic and adapting to a new working environment without the support of patient’ relatives

Table 3.4 Barrier related to insufficiency of human resource.

A working day includes 3

nurse&'morning shift; 2 nursesshift

on duty in the afternoon, evening,

and on weekends

Each nursing shift has2-3 nurses

Barrier related to insufficiency'

of human resource.The ICU at HML'H has a maximum

of to patients They divided the

numbeT of ICƯ patients to perform

the nursing care that accounted for

3-5 patient- nurse.' shift

nursing/patient averaged 1/5- 1/3 in a shift

Before and after COVID-19 nursing

workforce was still in a shortage, on

the other hand during the COVID-

19 period, the amount of nursing

work required to increase ĨỈ the

nursing patient ratio was 1/5 when

tliere are no specialized procedures

such as heart compressions,

implantation tubes, open results,

dialysis When there are

specialized ones, the ratio maybe is

1/9

The amount ofworkload increased, and the number of nurses remained the same previous time

Therefore, thepersonnel problem is exacerbated

Nursing found that large woxUoack

while insufficient nursing numbers

Lack of manpowei negatively affects the

resulted in inadequate patient care

and monitoring as before COVID-19

pandemic, negative affecting the

quality of care Tirus, it Iras a high

risk of causing medical errors

quality of care:

increased risk of medical errors

Nurses eat erratically or skip meals

For example, a shift from 7:00 am to

3:00 pm someone skips lunch and

works continuously until the end of

tile shift The reason is that the

human resources are thin and

overload working they try to get

enough work done before finishing a

shift time Conversely, if a nurse

goes to eat, the other person will

have to monitor and take care of all

10 patients at the same time / /

Maybe the mealtime only lasts for

15 minutes, but because of fatigue,

they loss of appetite

Nursing staff is limited, the workload

is large some nurses often skip meals so as not to intempt work and complete tasks during shifts/^ or due

TO fatigue

InCOVTD-19 pandemic, they could not handle them without the stress and complaint Leadiug from the problems with shortage of staff, the nuw to-patient ratio was indicated to be a problem, with the nurses sometimes having to care for more than three patients, from 1 /3 to 175 even 1 ■*?: