Introduction

Global Health Issues (GHI) demand interinstitutional and interprofessional work and collaboration for adequate planning, prevention, and care to address health equity issues among nations ¹.

Emerging infectious diseases, such as epidemics, are GHI problems as they cross country boundaries in a matter of hours or days. In this context, the deficit of healthcare resources, as well as healthcare providers and infrastructure, will negatively impact the prevention of emerging GHI in the population ¹, which raises a major issue of social justice, an essential concept for the nursing field ².

In human history three deadly epidemics have affected the population: the yellow fever of 1853 in New Orleans, cholera in 1832, and the Spanish flu (1918-1920) ³; the latter caused a mortality rate ranging from 60 % to 70 % ⁴, with more than 40 million deaths worldwide ⁵. Later, the Asian influenza (1957-1958) and the Hong Kong influenza (1968-1968) were less catastrophic, although they caused deaths along with economic and social issues ⁶. Currently, humanity is facing a pandemic as declared by the WHO ⁷; it is a respiratory disease named COVID-19, with characteristics similar to influenza in mild cases, which is transmitted from person to person and in severe cases can cause death ⁸, spreading to more than 200 countries and causing 5,087,688 deaths so far (November 11, 2021) ⁹. One of the main concerns regarding emerging infectious diseases is the prevention of the spread of these agents within healthcare settings ¹⁰.

There is no doubt that, throughout history, only a few pandemics have struck the world and -despite the fact that experience along with oral and written traditions are lost in time-, evidence has demonstrated that nursing professionals have been paramount in the recognition and response to emerging disease threats ¹, given that they occupy and assume vital positions and roles in care due to their expertise and unique professional roles with patients.

The International Council of Nurses (ICN) states that nurses are uniquely positioned to assist government healthcare agencies in implementing and evaluating disaster prevention and response measures internationally ¹¹. On the other hand, the American Nurses Association (ANA) provides valuable information and digital resources related to COVID-19 for use by nurses in all settings ¹².

Despite the wealth of information currently available, the review of the literature on nursing roles during pandemics is scarce up until 1968; subsequently, the number of references increases until information becomes plentiful in the current COVID-19 setting. Some studies report on the organizational aspect commenting on nursing care in typhoid fever ¹³, while other studies perform an evolutionary analysis of the influenza pandemic, and others focus on personal experience, providing very modest information on feelings of fear, isolation, and resentment during public health crises ^3,14 making it evident that, in the face of infectious diseases for which no treatment or vaccine is available, the healthcare teams' rates of unwillingness to work were higher ^15,16. However, although few studies have directly demonstrated how nurses have coped with these epidemic diseases ³, since the current pandemic context of COVID-19, plenty of varied and abundant information has become available.

In this context, and in the midst of the contingency that is currentlbeing experienced worldwide, it is essential to expose the true impact of pandemics on the role of nursing professionals. In light of this, a study was carried out with the objective of finding out what are the enablers and barriers to the fulfillment of nurses' professional role in times of pandemics and disasters.

Methodology

An integrative review was carried out aiming to obtain the best evidence and a summary of the literature that was objective, concise, and logical on the current knowledge of a particular topic ^17,18, for the specific case of this study, the COVID-19 pandemic. The information searched had no publication year limits up to 2021 in the Medline, Proquest, CINAHL, Web of Science, BVS, SpringerLink, Scopus, and Pubmed databases.

To formulate the research question, the PICO methodology ¹⁹ was used, resulting in the following question: What were the barriers and enablers for the fulfillment of the nursing role in the face of pandemics and disasters? To answer this question, the terms controlled and referenced in the thesaurus of Health Sciences Descriptors - DeCS- were used, with the simple analytical method named SALSA (Search, AppraisaL, Analysis and Synthesis) for systematic reviews ²⁰ (Figure 1) and using the following descriptors: nursing AND pandemic AND disaster AND coronavirus infection, in English, Spanish, and Portuguese. Using this method, 11,027 potential research studies were compiled for this study.

Source: Own elaboration.

Figure 1 Flowchart of the information selection process according to the SALSA method 

Once the studies had been selected, it was necessary to evaluate and classify the best existing evidence in the healthcare field for decision-making ²¹. For this purpose, a large number of proposals currently exist that rank the evidence accordingly, and one of them is the one proposed by the Agency for Healthcare Research and Quality (AHRQ) ²², which allows the levels of evidence to be classified using quantitative and qualitative approaches.

Results

The search strategy used achieved an initial retrieval of 11,031 potential articles for the study, out of which 32 articles were finally included in the final sample (Table 1).

Once the 32 selected studies had been evaluated (Table 1), it was observed that more than half of the articles stemmed from the Americas: Canada ^3,35, The USA ^{1,23-30,34,37,45}, Brazil ⁴⁷ and one article that refers to the American continent in general ³; the rest of the evidence is distributed across studies from Asia ^{10,14,32,38,40,42,43,44,49}, Europe ^39,41,46, Oceania ^6,31,48, and Africa ³³; therefore, all the articles are written in English. Regarding the journals where these articles were published, it was noted that all were published in journals indexed in the Proquest, Scopus, and Pubmed databases. In addition, it was evident that a large percentage of the retrieved articles did not state their design, and those articles that did had a level of evidence of 4 ^{14,24,26,30-34,42-45,48}.

Considering the objectives set and the results obtained, it is noted that all actions were focused on three main instances: a) Training and updating for role performance; b) Predictors, enablers, and enabling factors for exercising the role in the face of a pandemic; and, c) Evidence of the role in the face of pandemics. In light of this information, a synthesis of the evidence is presented in Tables 2, 3, and 4.

Discussion

In the study's integral analysis, it was found that all the articles retrieved were published in scientific journals indexed in the databases, which meet methodological quality standards and enjoy greater international recognition ⁵⁰. However, due to the historical characteristics of the information found in the first stage of collection, these articles presented a low level of evidence and used traditional historical methods for data collection, such as case studies and critical analysis of the social, political, and economic context in times of pandemics and disasters. Subsequently, the highest percentage of the information retrieved in the current COVID-19 pandemic context was mainly of a qualitative nature, being worth mentioning that the articles in these journals, originating from 16 countries worldwide, are in English, making the mastery of this language a pressing need and one of the main challenges for our profession since it is one of the tools that nursing professionals must possess to train and exchange knowledge ^51,52. It should be noted that a significant percentage of the evidence collected was obtained from databases with restricted access and in agreement with higher education centers; therefore, it is urgent to make effective agreements with healthcare professors to grant them access to these databases from healthcare centers, if research is to be done from a healthcare perspective.

Regarding the information obtained in this review, it is noted that the first studies found date back to the 1980s and contain little information regarding the role of nurses; later, in the current circumstances of the pandemic that humanity is experiencing, it is noted the report of sufficient and varied information that was useful in answering the research question.

According to the interpretation of the evidence collected, nursing professionals have had a reactive role in the face of emerging infectious diseases, that is, a rapid and immediate response in which they mainly fulfilled an assistance role, providing nursing care at home to families and the community in the face of an unexpected emerging public health issue. It should be noted that this reactive role also had its expressions inside the hospitals, carrying out its competencies to different services, but understanding that the preparation and experience were deficient in disasters and pandemics. Unfortunately, this action was deployed when emerging pandemic diseases were already present and their dissemination was imminent, both within and outside the borders of a country and/or continent.

Currently, as empirical knowledge advances along with the development of technologies, nursing graduates are starting to evolve in their professional work and in their visibility to society, managing direct care roles, becoming chaos managers, pandemic planners, health educators, and so on ²⁴, benefiting from their experience, knowledge and direct contact with the issue; these characteristics will undoubtedly be useful for the effective management of a recent emerging event and, of course, those to come.

It is undoubted, and the bibliography reports it, that in order to effectively perform the nursing role, it is necessary to invite nurses to reflect upon some ethical dilemmas that they must face in times of pandemics in their workplaces, first of all, questioning where their professional responsibilities begin and end, the existence of care protocols, work and contingency plans that the facility has in case of a pandemic, and the need for training and updates that should be provided by their employers since there is evidence reporting that nurses with limited training are less likely to stay on the job ¹⁴.

Regarding the evidence found, the results of this review coincide with other reviews retrieved ^53,54 regarding the barriers to the performance of their professional role; some of the relevant factors, which have been developed by several authors, are "fear" ^3,14,46, uncertainty ⁵⁵, psychological stress and the reluctance of healthcare professionals -especially nurses and nursing assistants ⁵⁶- to work with patients infected with emerging infectious diseases in an environment of scarce personal protective equipment ^46,48 and, therefore, the fear of bringing the infection to their homes and families ^48,57,58. This situation has not been addressed by governmental and health agencies, nor by the ICN (International Council of Nurses); the aforementioned institution, although it has recently published the 12 main priorities for the COVID-19 pandemic ⁵⁹, did not consider in any of the points of the declaration the protection of the fundamental pillar of every human being, and of course, of a healthcare professional, namely, their families. Failure to address this situation could lead to a setback in the effort to mitigate absenteeism and the deficit of human and material resources currently available to health systems ⁶⁰ since it is unquestionable that the nursing professionals' unwillingness to work is clearly related to the scarcity of personal protective equipment (PPE) ⁶¹, as well as to their personal safety and that of their families. Thus, a debatable ethical dilemma arises in the field of nursing regarding the moral obligation to provide care under any circumstances. The ICN ⁶², in the code of ethics that governs nursing practice, emphasizes in the section "The nurse and practice", the moral autonomy that nursing professionals have in the development of their professional practice, mentioning that they "will maintain a level of personal health that does not compromise their ability to provide care". In this sense, the American Nursing Association (ANA) ² also develops the idea of autonomy in the practice of nursing without compromising health, stating in its provision number 5: "nurses owe the same duties to themselves as they owe to others, including the responsibility to promote health and safety".

An enabling element for the implementation of the professional role in times of pandemic is to consider, on one hand, nursing professionals as "constructive" support that has characteristics of resilience, self-care, and adaptability; and on the other hand, the aspect raised by some authors ¹ stating that if nursing professionals want to have a successful impact in the fight against emerging global health issues, they must develop leadership skills and strengthen interdisciplinary work ⁴⁶, directing their focus beyond the hospital wards and healthcare settings, with an understanding of the broader context. This is stated by the Canadian Nurse Association ⁶³, an organization that proposes eight essential competencies for nurse leaders in 2020; they approach leadership from a global perspective in the face of health and professional nursing issues. This approach allows the dynamic interaction of nurses at all levels of care, preferably in community health nursing activities with individuals, families, and the community, granting them the opportunity to become innovative agents of change ^{(1, 24)}. In this context, one author ⁶⁴ argues that it is imperative to support a change agent by evidence-based practice, this being the framework in which nurses begin prevention, early recognition, intervention, and implementation of practices and programs to address these issues, actions that in the perspective of the results achieved in this study, and the onsite experience of the authors, should be worked upon immediately.

Another element that the literature reports as an enabler, and that conditions the development of the professional role, is related to the training that future nurses receive in nursing schools and colleges ⁶⁵; These should encourage a change in curricular innovation, incorporating in their curricula policies, guidelines, and experiences in the simulation of epidemics and/or catastrophes, and even in preparation for bereavement counseling since the community and patients expect expert care and specific training in such areas, which can reassure them regarding the competencies of nurses. This training in times of pandemics, not only can be contemplated from the formal academic environment, but also from the need to constitute a non-professional nursing capacity whose objective would be to have a second line of nurses with basic training to provide care, as a viable alternative if there is a need for additional human resources to provide care to the community. In this regard, some authors state ³¹ that, although "informal" training is necessary in times of pandemics, it must be strongly protected so as to not cross professional boundaries since in the future there could be a serious risk of becoming dependent on these volunteers with basic knowledge in situations in which nurses become massively ill or decide to refuse to work. Faced with this issue, the authors agree with some studies ³⁵ which suggest that, faced with a deficit of nurses in times of pandemics, a call should be made to allow the arrival of immigrant nursing professionals from countries less affected by the pandemic; this would respond to one of the 12 priorities of the ICN in the face of the COVID-19 pandemic ⁵⁹, since in its priority number 6 they comment that when faced with a deficit of nursing professionals, "an effective response in terms of registration and regulation should be provided by rapidly increasing the nursing staff". In addition, they demand that, in order to rapidly increase the number of nurses, the graduation of students or the reinstatement of retired nurses should be accelerated, ignoring the fact that this skilled workforce of immigrant nurses may be better prepared than students and retired nurses.

Ultimately, to ensure that an adequate frontline nursing workforce is in place, while simultaneously ensuring that the autonomous role of the frontline nurses is fulfilled during a pandemic and/or disaster, a number of issues need to be addressed: pre-planning by employers, training, and updates prior to and during pandemic crises, provision of full personal protective equipment to provide safety for frontline staff, ensuring a safe environment for the nursing team and a holistic environment in their workplace by providing resting and feeding areas, shift rotation of work teams, psychological support, incentives, and life insurance, religious facilities, transportation in case of social restrictions, ensuring the frontline nursing team and their families easy access to medications, vaccinations, nursing homes, and psychological support; and finally, to provide incentives and life insurance for frontline staff.

Conclusion

This study allowed, firstly, to identify the barriers and enablers that allow or hinder the fulfillment of nurses' professional role in the face of pandemics or catastrophes; secondly, to understand that emerging infectious diseases should be addressed immediately and collaboratively by governmental and local agencies and, ideally, in a preventive manner once they emerge, with a complex and multidisciplinary approach.

With the information collected, it is possible to change the paradigm that nursing is only a technical and reactive profession in the face of emerging health crises since the work of nurses goes beyond care: it encompasses management, education, and research, so that the community recognizes the importance of nursing and can be confident that these professionals will be there to take care of them in the event of an unexpected pandemic event, thus developing a much more proactive and visible professional role in their social actions.

Limitations

A relevant limitation to consider is that the articles retrieved in this review were evaluated by a single researcher; therefore, there is a possibility that the data could be biased. Since the review results are from 16 countries spanning across different continents, these countries may hold different cultural perspectives or beliefs regarding this pandemic, so the synthesis of issues in this review may not be applicable to all populations of nurses worldwide.