A nursing informatics response to COVID‐19: Perspectives from five regions of the world

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Abstract

The 21st century has seen several infectious disease outbreaks that have turned into epidemics and pandemics including Severe Acute Respiratory Syndrome (SARS) which began in Asia in 2003 (Poon, Guan, Nicholls, Yuen, & Peiris, 2004), followed by H1N1 that emerged in Mexico and the United States (US) in 2009 (Belongia et al., 2010). Next came the lesser known Middle East Respiratory Syndrome (MERS) originating in Saudi Arabia in 2012 (Assiri et al., 2013), after which the Ebola outbreak in West Africa took place from 2014–2016, with a more recent occurrence in the Democratic Republic of Congo from 2018–2019 (Malvy, McElroy, de Clerck, Günther, & van Griensven, 2019). To date, the coronavirus (COVID-19) outbreak that started in Wuhan, in the Hubei province of China, in late December 2019 seems to be eclipsing all of these previous infectious diseases in terms of its global reach and impact (Wang, Horby, Hayden, & Gao, 2020). After being declared by the World Health Organization (WHO) as a public health emergency on 30 January 2020 (World Health Organization, 2020c), it was elevated to a pandemic status on 11 March 2020 (World Health Organization, 2020d). As of 28 April 2020, there are more than 2.9 million cases and 202,597 deaths reported worldwide (World Health Organization, 2020b). Healthcare workers around the world, for example nurses, medical doctors and community healthcare workers are on the front lines caring for those infected (Zhang, Sun, Latour, Hu, & Qian, 2020), whereas epidemiologists, public health officials, and others work behind the scenes to control the spread of COVID-19 and protect population health. Scientists across many disciplines are also researching how to address the myriad problems that this disease has created and exacerbated, such as the shortage of personal protective equipment (Chughtai, Seale, Islam, Owais, & Macintyre, 2020), the need for more critical care facilities and expertise (Grasselli, Pesenti, & Cecconi, 2020), the development of therapeutics (Dhama et al., 2020) and new vaccines that could prevent the virus in the future (Anderson, Heesterbeek, Klinkenberg, & Hollingsworth, 2020). Nursing informaticians who use information technology to enhance nursing education, clinical practice and policy are collaborating with colleagues and contributing to and leading research and digital health initiatives in the face of COVID-19. Here, we discuss some perspectives from nursing informaticians based in nine countries across five regions of the world (Ronquillo, Topaz, Pruinelli, Peltonen, & Nibber, 2017). We explain how the nursing informatics community is responding to this global crisis and offer some early lessons learned that could be useful in future outbreaks of infectious disease. Despite the swift implementation of a lockdown of the Hubei province, COVID-19 spread beyond Chinese borders. Approximately 400,000 people cross the shared border between Hong Kong and China per day (Hong Kong Immigration Department, 2020), posing a risk of repeating the SARS outbreak more than a decade earlier that killed 299 people in Hong Kong (World Health Organization, 2003). Within days of the first reported case of coronavirus, the Hong Kong government raised the response level to ‘emergency’ (Cheung, Lok-kei, Lau, & Ho-him, 2020). This saw the halting of transportation to and from Wuhan, the cancellation of large events in spite of the Lunar New Year celebrations, an extension of school holidays and work from home arrangements (Lum & Lok-kei, 2020). However, the outbreak triggered painful memories of the 2003 SARS epidemic for many residents who were already mired in a time of civil unrest and government dissatisfaction throughout 2019 and 2020 (Lau & Cheung, 2020; Stevenson, Ramzy, & May, 2020). Despite the government justifying the maintenance of its borders with China, pressure from the public and healthcare workers, as well as a burgeoning rise in local COVID-19 cases led to border closures and the suspension of schools and examinations (Ho-him, 2020). In response, nursing informaticians in Hong Kong are helping to move nursing education fully online to support students, while teaching about this new infectious disease through social media and developing virtual learning activities around public health interventions. Among Southeast Asian nations, the Philippines ranks high on the list of countries with the total number of cases and deaths from COVID-19 (Center for Strategic & International Studies, 2020). The government placed the largest of the islands, Luzon which includes the capital city of Manila (home to about 60 million people), in enhanced community quarantine (i.e. lockdown) on 16 March 2020 to reduce the impact of the disease on the country's healthcare system (Gregorio, 2020). Despite being a top global exporter of healthcare workers (Castro-Palaganas et al., 2017), the Philippines is now experiencing a lack of nurses and other clinicians to serve during the pandemic. As a result, the government called for healthcare worker volunteers in March (Cruz-Bacani, 2020) and temporarily banned overseas deployment of healthcare workers in April 2020 (ABS-CBN News, 2020b). The main nursing associations including the Philippine Nurses Association, Filipino Nurses United and Ang Nars are urging the government to give nurses higher wages, on top of the ₱500 pesos (USD $10) per day allowance announced, to mitigate nurse migration and ensure they are adequately compensated for the high risk, critical role they provide caring for people infected with COVID-19 (ABS-CBN News, 2020a; deLeon, 2020). In response to the pandemic, nursing informaticians in the Philippines are helping to deploy distance learning and e-learning technologies to ensure nursing students and professionals are adequately trained. Social media are also being used to disseminate appropriate health information to local communities across the numerous islands and provide emotional support to nurses working on the frontlines caring for those infected. Like other regions, COVID-19 quickly spread to almost all parts of the Middle East. The Kingdom of Saudi Arabia is one of the countries in the Arab world that has been significantly affected with more than 20,000 cases (Abueish, 2020). The holy month of Ramadan which requires fasting, prayer and reflection started on the evening of the 23 April 2020 and lasts for 30days which could make self-isolation and social distancing challenging (Atique & Itumalla, 2020). In addition, millions of Muslims would normally undertake the Umrah, an Islamic pilgrimage to Mecca, which the government cancelled in a bid to repress the spread of the disease (Ebrahim & Memish, 2020; Gautret, Al-Tawfiq, & Hoang, 2020). The Middle Eastern region, especially the Kingdom of Saudi Arabia, is already facing the MERS and therefore further vigilance is required to combat COVID-19 (Jazieh et al., 2020). The Ministry of Health has directed healthcare workers to strictly follow the previous guidelines for MERS as this is an emerging and complex situation (Ministry of Health, 2020). The country largely relies on a foreign workforce which comes from around the globe to staff its health sector, bringing knowledge and skills from a diverse range of nationalities and ethnicities. Furthermore, some hospitals have started telemedicine and related digital services to provide health care to people at home (Saudi German Hospitals, 2020). In response to the pandemic, nursing informaticians in the Kingdom of Saudi Arabia are helping to provide digital health and care services such as telemedicine. They are also using online tools to reach and educate patients and local communities about the disease to help reduce transmission and rates of infection. Europe was the epicentre of the pandemic for several weeks, with Belgium, Italy, Spain, and the United Kingdom (UK) among the countries with the highest number of reported cases and deaths from COVID-19 (Henley & Pilkington, 2020). In the UK, the Prime Minister Boris Johnston, who was hospitalized in critical care with the coronavirus (Stewart & Campbell, 2020) and the Tory political party that holds the government majority, initially took an alternative approach to tackling the disease by advocating for ‘herd immunity’ on 12 March 2020 (Yong, 2020). The Tory party leadership suggested that most of the population, approximately 65 million across four countries (England, Northern Ireland, Scotland and Wales), should become infected to enable healthy individuals to build up an adequate immune response to this contagious disease (Horton, 2020). This was followed by mixed messages around social distancing and self-isolation mid-March 2020, despite the rapidly rising death tolls in Italy and Spain where British citizens were holidaying at the time (Hunter, 2020). It has garnered a varied response from professionals and the public alike, both at home and abroad, given this does not follow the traditional public health response to an infectious disease outbreak that includes testing, contact tracing and isolating potentially infected individuals (Alwan et al., 2020; Hellewell et al., 2020). Despite a change in UK government policy away from this approach, some of the conversations surrounding this debacle and others such as the shortage of personal protective equipment and critical care beds have reverberated on social media. These data are now being analysed by nursing informaticians, as Twitter and other online platforms can be used to discern trends in the public's perception of important health-related issues which can be used to inform and promote health protection (Meng, Kath, Li, & Nguyen, 2017). Other nurse informaticians are working to develop digital dashboards to monitor and improve the quality of care in acute hospital settings (Randell et al., 2020) or testing virtual reality applications as a way to improve mental health (O'Connor, 2019). Switzerland, a country with 8.6 million inhabitants living across 26 cantons and four language regions (French, German, Italian and Rhaeto-Romance), is responding to the COVID-19 pandemic by closing non-vital services and implementing WHO recommendations such as rapid testing, case isolation or self-isolation and social distancing (Federal Office of Public Health, 2020; Salathé et al., 2020). Like many countries, the health service and frontline clinicians face numerous challenges such as the shortage of personal protective equipment, disinfectant and ventilators and a lack of knowledge on how to prevent, diagnose and treat the disease. These rapid changes have expediated a digital transformation in Switzerland with family doctors and hospital laboratories exchanging data in more structured, electronic ways and patients remotely monitored by nurses and physicians using telemedicine or telecare systems (Wanner, 2020). In addition, numerous scientific research initiatives have begun to address some of these challenges. One example is the Corona Science community, an interdisciplinary group of researchers including nursing informaticians, who are working with sponsors and partners to provide an application to collect anonymized, aggregated self-reported data related to COVID-19. This includes measures for physical health, psychological well-being and social impact, for example employment, education and home schooling, caring responsibilities and community activism, to enable a better understanding of this infectious disease (Corona Science, 2020). In Finland, the government declared a state of emergency in March 2020 and implemented a range of measures including closing most educational institutions and shifting to online education, closing businesses and cultural venues, limiting travel and banning large gatherings to curb the spread of the virus. The southern region of Uusimaa, where the capital Helsinki lies and where many of the 5.5 million citizens live, faced tougher restrictions to limit the transmission of COVID-19 to the rest of the country. These restrictions are planned to remain in force until the 13 May 2020. On 1 April 2020, an Operations Centre for managing the pandemic was established by the Prime Minister's Office to improve situational awareness, monitor the impact of government policies on the coronavirus outbreak and develop an exit plan (Finnish Government, 2020b). In addition, an arm of the government called Media Pool, which supports media organizations in Finland and a marketing company, PINK Helsinki, jointly launched a national social media campaign to counteract misinformation about the infectious disease (Finnish Government, 2020a). Nationally, the Finish Institute for Health and Welfare continuously update their online resources with information and materials on COVID-19 for professionals and the public (Finnish Institute for Health & Welfare, 2020). Existing digital health services have also been expanded. For example an online symptom assessment tool called ‘Omaolo’ is available to help the public gauge the likelihood of a coronavirus infection and provide referral and treatment advice (SoteDigi Oy, 2020). A ‘Coronabot’ web service that gives guidance regarding exposure to and symptoms of COVID-19 has also been established and a national online database for professionals was updated with COVID-19 specific information and guidance via a collaboration across university hospital districts of Helsinki, Tampere, Oulu, Kupio and Turku (Health Village, 2020). Nursing informaticians in Finland have assisted these efforts and beyond e.g. by developing COVID-19 related data interfaces for electronic health records, providing digital education on caring for those infected with the virus and improving mobile documentation to speed up access to real-time patient information. In Canada, the structure of healthcare provisioning is determined by provincial governments which has resulted in variations in the public health and political response to the COVID-19 pandemic. Nevertheless, there are concerted efforts across the country to focus public education and policy on physical distancing as a key strategy to ‘flattening the curve’ and preserving a level of acute care capacity for those that need it (Woods, 2020). This has led to a restructuring of healthcare service delivery via the increased use of health information technologies. In Western Canada, there has been a push for virtual health teams to increase capacity for telehealth appointments (e.g. telephone, video conferencing, email and text) to deliver patient care (Provincial Health Services Authority, 2020). This rapid development and implementation of digital services has required nursing informaticians to lead much of this work. Furthermore, virtual teaching tools have been created to help prepare nurses, nursing students and retired nurses entering frontline health services to support COVID-19 efforts.These include online educational resources related to the clinical presentation, detection and care (e.g. e-learning module on the use of personal protective equipment) of people diagnosed or suspected to have the infectious disease (Canadian Institute of Health Information, 2020; Canadian Nurses Association, 2020). A systematic and centralized approach to collecting, coding (using the WHO International Classification of Disease), synthesizing and sharing up-to-date information about coronavirus cases is also underway among the health informatics community, who are adopting new digital and visualization tools to enable better epidemiological modelling (Canadian Institute of Health Information, 2020). In the US, the federalist system of public health governance divides power among the federal, state and local governments. Each of these entities has an authority, to some extent, to initiate responses to the COVID-19 pandemic. Early in March 2020, federal government in the US started its response by introducing a travel ban on flights from China. Further federal policies included declaring a national ‘State of Emergency’ and providing financial stimuli to the US economy (Wallach & Myers, 2020). Although responses varied from state to state, virtually all states issued stay-at-home orders for non-essential workers as of early April 2020 (National Conference of State Legislatures, 2020). In late April 2020, the situation remains dire, with the US becoming an epicentre of COVID-19 cases and deaths worldwide. Nursing informaticians in the US have responded to the COVID-19 pandemic in several important ways. In educational settings, nursing informaticians have supported the switch to online modes of education to reduce in-person contact between nursing students. In clinical settings, nurse informaticians are using a diverse range of health data to help alleviate the impact of COVID-19. For example, nurse informaticians across hospitals in New York have built efficient and streamlined ways of tracking the availability of and forecasting the need for critical health equipment such as ventilators. In other initiatives, nurse informaticians are collaborating on providing access to timely data, for example guidelines on nursing responses to the COVID-19 pandemic (Omaha System Community of Practice, 2020). In addition, nurse informaticians have contributed to creating ways of assessing COVID-19 related symptoms; for example by assisting in the creation of an online survey, CovidWatcher, that tracks disease symptoms (University of Columbia, 2020). Finally, Latin America and the Caribbean have been the last major region of the world to experience the coronavirus. The government and public response to COVID-19 has varied due to the differing health systems, economies and politics of each country. However, high levels of inequality and poverty (Santos & Villatoro, 2018), along with limited health systems capacity and a lack of healthcare workers are common characteristics amongst many Latin American countries (Laurell & Giovanella, 2018). The first coronavirus case was in on 26 2020 and was the first country to a death on March 2020 related to COVID-19 (World Health Organization, 2020a). The in Latin America is with a of individuals 65 American Health Organization, 2017). Despite a the in health, access to health care and the of diseases the of care & 2019). 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To nursing informaticians worldwide are working with colleagues in clinical settings to and electronic systems and digital that supports healthcare professionals caring for patients with while those in educational settings prepare and deliver virtual learning to nursing students and nurse about the infectious disease. nursing informaticians are also researching how technologies can be to the spread of the virus and its impact on health and early lessons learned during this pandemic are to interdisciplinary to platforms for symptom and disease with the technology to up digital for health patients and their and on social media and health applications to reach key quickly such as at risk work to be in by and visualization tools on real-time COVID-19 to enhance by policy and the The nursing informatics community plan to in for their in after the 2020 Here, COVID-19 and how it is being across the regions of the world is to that the cultural and political challenges we face can be and new about how technology and informatics can help nurses address are As 2020 is the World Health Organization (WHO) Year of the and the we this to nurses who are helping the coronavirus pandemic, those who have their to this infectious disease. of the of the of Information, The of at for providing the time and resources to this The other financial support for the of this

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