Rehearsing for improvisation was identified as the core category, delineating how emergency nurses thrived in uncertainty and change in various areas of their practice during epidemics. Four interplaying sub-categories were identified: (1) sensing the unclear situation, (2) equipping for the impending battle, (3) calibrating to the evolving guidelines, and (4) navigating the new role and duties. These categories present the emergency nurses’ strategies in addressing uncertainty and change while engaging in EID management.
Rehearsing for Improvisation
While it may seem oxymoronic to describe a behaviour of rehearsing for improvisation, the findings revealed that emergency nurses were required to prepare and equip themselves with skills and techniques to improvise appropriate decisions and actions in addressing changes and uncertainty during an epidemic. In this circumstance, everyday duties posed challenges to their physical, emotional, and psychological capacity to adapt. The comment below illustrates how an experienced emergency nurse responded to untoward incidents when engaged in EID management:
Various unexpected issues that demand our action come all of a sudden, and we are unable to stop or control them. At this moment, it is time to examine our ability to stand the test of these challenges. It tests our leadership, our problem-solving skills, and our ability to improvise. In addition, it challenges our critical thinking skills and decision-making abilities. These are all crucial as we work in the accident and emergency department, especially in the midst of unpredictable and unforeseen events. (P16)
This view was echoed by another participant, who indicated that technical solutions were inadequate and unavailable for emergency nurses to handle unexpected issues while engaged in EID duties. The participant remarked that it was crucial to identify alternatives and respond to issues on an impromptu, rather than on a prepared basis:
It could be chaotic and problematic in managing EID. We are not able to predict what is ahead waiting for us to handle. Things can happen in a way that is poles apart from what is written in the protocol. (P14)
This participant went on to share his experience in an incident during the period of the Ebola virus disease outbreak, while a patient with suspected infection displayed uncooperative and aggressive behaviour:
There was once a suspected Ebola case transferred to our department via ambulance. The patient had developed signs of infection, therefore we considered him to be high risk and arranged an isolated room for quarantine purposes. But then the patient started to be uncooperative and aggressive, perhaps because of communication problems, as the patient was from an ethnic minority and there was no interpreter available at that moment. Suddenly he turned violent and assaulted our staff and we had to subdue and restrain him, while we had no time to gown up in PPE. At that time, we were so helpless and we were afraid of being infected. The guidelines and protocols did not mention what we could do in this situation, and we had to count on ourselves. (P14)
This incident showcased a situation emergency nurses encountered while engaging in EID management of an unpredictable and unexpected event, as described by some participants, that “stirred up troubles”. Instead of following established protocol, emergency nurses were required to prepare and equip themselves with skills and strategies to improvise and adapt in such a situation.
(1) Sensing the unclear situation
Some participants expressed the belief that the most pertinent way to resolve uncertainty was to obtain relevant information to address any erratic situations. Indeed, gathering up-to-date information was considered by participants to be a crucial component for emergency nurses to acquire a general picture of the nature and progress of an EID scenario, enabling them to orientate themselves to the circumstances. A participant highlighted the importance of obtaining relevant information when gaining familiarity with an EID scenario as follows:
It is of the utmost importance that you know what is happening. As long as you understand the situation, you realize the problem. You have to acquire the latest information and maintain an up-to-date understanding of the situation. (P16)
One of the major concerns raised by the participants was about the quality of the information, as some of them pointed out that the information they received was not standardized. Participants stated that the information provided by their colleagues, which included disease information, infection control guidelines, and patient logistics protocols, was sometimes inconsistent, leading to confusion. Although they worked in two different hospitals, these two participants held similar opinions about the inconsistency of the information they received. One of the participants described the problem as follows:
The information could sometimes be regarded as ‘hearsay’. Perhaps one staff member had said something about the disease, then others started to discuss and circulate the information. However, no one had confirmed the creditability or sources of that piece of information. The information might be distorted, exaggerated, or even misleading. However, we do not have an official and standardized source for obtaining information, and therefore hearsay persists among staff. (P20)
While facing issues such as information overload and inconsistent information, participants highlighted that personal alertness and vigilance were also required in addressing the unclear situations they were facing, instead of depending entirely on provided information. In their everyday work, emergency nurses served as gatekeepers who were closely connected to the community, which helped provide clues as to the disease trend and progress and allowed them to reveal the development of the general disease situation. The comment below illustrates how a participant recognized the outbreak of H1N1 influenza through engaging in routine practice:
You know about the disease situation and progress at work, especially if you are the triage nurse. There was a large number of patients attending AED and eight out of 10 had similar flu-like symptoms, you would then realize and be able to tell, there was something wrong, it was the influenza that was causing this. Then you read the news, and took note of the announcement from the Department of Health about recent outbreaks, and you would be alert as to what you had just come across at work. So, you started to pay attention to the outbreak-affected regions, the mortality rate and the prognosis. You experienced it and sensed it. This sense did not merely improve your alertness, but also provided you with the whole picture of the outbreak, including the severity, the magnitude and the extent. (P17)
(2) Equipping for the impending battle
Participants referred to EID management amidst uncertainty as analogous to a “battle”, implying that it was an immense hardship for them and they were required to prepare beforehand and be well-equipped to conquer the battle against EIDs. It was suggested by the participants that they had to equip themselves with relevant knowledge and skills, in order to bolster their readiness both theoretically and practically, to respond to an epidemic event. For instance, one participant, who had extensive experience in emergency care, suggested that holding the relevant knowledge of an EID was a basic necessity for their participation in an outbreak response:
Sometimes there are junior colleagues making mistakes in simple tasks while handling EID cases. The main reason is that they are not familiar with this type of knowledge. I often ask them to do some infectious diseases revision. This is basic for emergency nurses. For example, being able to identify the signs and symptoms of an EID is the most important task in EID management, but if the nurse did not have the related knowledge, how can one differentiate infected patients from the others? (P17)
Indeed, engaging in EID event management required emergency nurses to demonstrate proficiency in a variety of skills and techniques. The participants reported that this specific skill set, which included but was not limited to clinical assessment skills and precautionary measures, enabled them to accomplish various unforeseeable tasks in an effective and proper manner while engaged in EID management. An advanced practice nurse highlighted the necessity of emergency nurses to develop the skill of rapid and accurate clinical assessment for patient surveillance as follows:
An accurate primary assessment is the basic skill an emergency nurse should have, especially at the initial triage. It is very important for us to really learn and be proficient in this skill, because on some occasions, we only have a few seconds to make a triage decision. For example, imagine I am the triage nurse, and you are a patient walking towards me. While you are walking, I am already assessing your condition, from your gait, your power, your posture, and your breath. Combined with a patient’s past health history, vital signs, and chief complaints, I will have a preliminary picture of their condition. Treatment could then be initiated if needed. (P21)
Considering the importance of obtaining pertinent knowledge and skills, there was a variety of sources for emergency nurses to receive relevant education and learn the required techniques for engaging in EID management, such as workshops and drills. These training, as described by the participants, offered opportunities to AED staff to familiarize themselves with the process and procedure of managing epidemic events, which were not certain but likely to occur. One participant shared her experience of an Ebola drill, commenting as follows:
There was an Ebola drill in our department not long ago. We participated in a simulation for the admission of a patient with confirmed Ebola infection into the AED. It started from the very beginning, from receiving a phone call from the ambulance for the admission of the Ebola case, to triage, to the treatment and arrangement. Staff were assigned to different roles in the drill, such as triage nurse and nursing officer in-charge. We can learn and reinforce the importance of infection control through the drill. We will know how to manage this kind of contingency if they really encounter such an issue in the future. (P16)
Indeed, participants agreed that conducting training in a simulated environment offered a platform to assist emergency nurses in preparing for an epidemic event, and in enhancing their performance to respond to an EID scenario. Yet, the participants highlighted that it was also necessary for emergency nurses to accumulate clinical experience to establish their readiness and proficiency in EID management, which was irreplaceable, and would not be possible by only doing drills and receiving instruction. As asserted by the participants, prolonged engagement in clinical settings offered a benefit to emergency nurses, because clinical wisdom could only be developed by immersing themselves in the substantial aspects of everyday practice. The comment below illustrates a participant’s opinion on the significance of accumulated clinical experience on establishing readiness in managing an unanticipated situation:
In the management of EIDs, there are enormous unexpected issues that one might have no idea about how to handle, unless one had accumulated clinical experience or there were others who could share their own experience. It would be difficult for a junior emergency nurse, who had never come across similar issues in reality, to figure out a solution, even if he had attended workshops or drills before. Only if he had actually experienced this type of issue before, could he identify the possible difficulties that might emerge. Then he would have learned from the experience and be ready to handle similar situations in the future. (P22)
(3) Calibrating to evolving guidelines
The development of an EID situation could wield enormous influences on the implementation of precautionary measures. Among the various indicators depicting the progress of an EID situation, the enacting of the three-tier response level (Alert, Serious, and Emergency) was regarded by participants as the most decisive consideration for their hospitals and departments in stepping up the requirements for routine infection control practice. Stringent infection control recommendations were established to tie in with the exacerbation of the disease situation. Most participants valued the relevance of these accelerated infection control measures in protecting both healthcare personnel and the public from EIDs. However, the changes also impacted emergency service delivery. Some participants did not feel confident about their readiness to adhere to the guideline changes due to lack of practice, although instructions were provided. They commented that there were distinct differences between the new recommendations and the practices they had been accustomed to following, which caused additional complications in successfully implementing the new recommendations. One participant expressed concerns about adhering to the updated PPE guidance in an Ebola response, depicting an example of the challenges emergency nurses might encounter in terms of guideline changes:
There are new recommendations on the standard of the PPE kits for use in handling patients with suspected or confirmed Ebola infection, including a new gown, thicker gloves, additional rain boots, and an extra hood. It is different from the one we are used to using when dealing with other infectious diseases. Not only the equipment, but also the methods and sequences in equipping and removing the gear are totally new to us. Although we have been told and taught in workshops how to utilize the new PPE, it is still difficult for us to be readily familiar with the new recommendations without an opportunity to practice. (P17)
With regard to the implementation of new measurements and protocols, participants had underlined the significance of the idea of calibration, in which new guidelines and recommendations were scrutinized, selectively extracted and adjusted to fit the particular situation in practice. The comment below illustrates how a participant described the process of calibration:
Learning from new guidelines and recommendations is like peeling an onion - you peel off something layer by layer. What is left behind is something that could be incorporated into clinical practice. We should understand that what we have learned or adopted formerly is valuable, and what we are doing now is renewing it to fit the situation. We do not have to do everything by the book. Instead, we should adapt to the process, and adapt to the situation. (P26)
Indeed, many participants suggested that it was of paramount importance to value both their experience and the new recommendations through calibration. They might develop a tailored set of practices through integrating the new recommendations into their experience, enabling them to adapt to the novel needs of EID management. One participant illustrated his experience in adapting to the changes in routine as follows:
In handling a new situation, coping with new challenges, your experience is always invaluable. However, it is important to understand the core intentions embedded in the new guidelines and recommendations, and combine what I have learned with the new knowledge. I would filter the new guidelines and apply them alongside my original set of practices, as long as those guidelines do not violate the basic principles of what I have established from my clinical experience. It is the essence of the new guidelines that I should take into account, but not rigidly adhere to any recommendations. (P14)
(4) Navigating the new role and duties
In facing an EID event, the scope of emergency healthcare services would be broadened with more emphasis on infection prevention and control, on top of the usual life-saving practice of emergency care provision. Although all participants acknowledged emergency nurses’ responsibilities in an epidemic event response, some encountered difficulties embodying the extended role in practice. Some participants commented that the responsibilities and duties of their role as an emergency nurse had changed when they were engaged in EID management. They suggested that adjusting to the altered role was challenging, because there was a lack of clarity surrounding their role and orientation in the midst of an epidemic event. For instance, one participant, who was relatively new to the emergency care setting, expressed concerns about articulating the role expectations that accompanied the responsibilities of an emergency nurse in the H7N9 avian influenza scenario, as follows:
In the course of EID management, I have a feeling that I am not working in an AED. I formerly expected that the role of an emergency nurse was to triage patients according to their conditions and offer care to those who were in critical and urgent need. But now my role has changed all of a sudden and I am mainly assigned to duties on infection prevention. It is true that the guidelines and measures for disease prevention and infection control have been put in place, but the problem is, I personally am not yet in place. (P12)
On this topic, a participant who served as a department operations manager and was regarded as being in a higher management position, offered an explanation for the instruction of minimal intervention in suspected Ebola cases. She highlighted the importance of maintaining an open mind while facing a significant change in work practices, in the following way:
Ideally, we should do everything we can for patients, and this is what we always do in AEDs. However, we should also consider the outcomes and consequences of our actions and interventions. For patients with Ebola, resuscitation might not do much good for them while at the same time, it might subject our staff to a risk of infection. There are various issues we have to consider when making a decision, and therefore we have to be flexible and remain open on these grounds, rather than sticking to the same old rut all the time. (P26)
A few participants agreed that working adaptively and flexibly was the essential attribute of emergency nurses in navigating their altered role in accommodating evolving needs during EID management. They generally acknowledged and displayed an acceptance of the extended role, and endeavoured to cultivate adaptiveness and assimilate the duty and responsibility of infection prevention into their regular work practices. As one participant put it:
Sometimes one should allow changes to take place and show openness towards the changes. Now, I can say the practice of infection control has seemingly integrated as a usual component into my emergency care practice, regardless of the alert level and disease situation. It is a process that takes time. (P13)