Article

A Glance at the Barriers and Enablers of the Nursing Role in Pandemics:
An Integrative Review

Una mirada a las barreras y los factores facilitadores del rol de la enfermería en las pandemias:
revisión integrativa

Uma visão às barreiras e aos fatores facilitadores do papel da enfermagem nas pandemias:
revisão integrativa

10.5294/aqui.2022.22.1.4

Juan Domingo Reyes-Luna ¹ ,
Patricia del Tránsito Jara-Concha ²

¹ 0000-0002-4862-9700 Universidad de Concepción, Chile. [email protected]

² 0000-0003-1580-3976 Universidad de Concepción, Chile. [email protected]

Received: 19/10/2020
Sent to peers: 16/12/2020
Approved by peers: 27/09/2021
Accepted: 30/09/2021

Subject: evidence-based practice.

Contribution to the subject: it is relevant in that it identifies specific phenomena and more general aspects of nursing practice during pandemics, which can be transformed into research opportunities using diverse theoretical references. Among the specific phenomena are nurses' fear of contagion and death in their personal and family environments; among the general aspects are the barriers, enablers, and ethical dilemmas that these professionals have faced in carrying out their role during the pandemic that is currently challenging humanity. The information in this article is a contribution to be contemplated by nursing professionals to address the development of their role in an emergency situation in a proactive, immediate, collaborative and multidisciplinary way.

Para citar este artículo / To reference this article / Para citar este artigo: Reyes-Luna JD, Jara-Concha P. A glance at the barriers and enablers of the nursing role in pandemics: an integrative review. Aquichan. 2022;22(1):e2214. DOI: https://doi.org/10.5294/aqui.2022.22.1.4

Abstract

Objective: to analyze the enablers and barriers to nurses' professional role fulfillment during pandemics and disasters.
Materials and methods: this was an integrative review based on the SALSA analytical method, carried out in eight databases, namely: Medline, Proquest, CINAHL, Web of Science, BVS, SpringerLink, Scopus, and Pubmed. The descriptors used were the following: 'nurse's role' AND 'pandemic' AND 'patient' AND 'coronavirus infection', in English, Spanish and Portuguese. Filters along with inclusion and exclusion criteria were applied to the 11,031 articles found, after which the final sample consisted of a total of 32 articles.
Results: considering the objectives set and the results obtained, it is noted that all actions focused on three main instances, namely: a) training and updating for role performance; b) predictors, enablers, and barriers for exercising the role in the face of a pandemic; and c) evidence of the role in the face of pandemics.
Conclusion: this study allowed understanding both the barriers and the enablers that allow the fulfillment of nurses' professional role in the face of pandemics or catastrophes. It also clarified that emerging infectious diseases must be addressed in an immediate, collaborative, and multidisciplinary way. Nurses' experience, leadership, and professional training are key attributes that these professionals possess to enable their role to be more proactive during an emergency situation.

Keywords (Source DeCS): Nurse's role; pandemics; community health nursing; nurse clinicians; coronavirus infections.

Resumen

Objetivo: analizar los factores facilitadores y las barreras para el cumplimiento del rol profesional de las enfermeras y enfermeros en tiempos de pandemia y desastres.
Material y método: revisión integrativa según método analítico SALSA, realizada en ocho bases de datos: Medline, Proquest, CINAHL, Web of Science, BVS, SpringerLink, Scopus y Pubmed. Los descriptores utilizados fueron: 'rol de la enfermera' AND 'pandemia' AND 'paciente' AND 'infección por coronavirus', en idiomas inglés, español y portugués. A los 11.031 artículos encontrados se aplicaron filtros y criterios de inclusión y exclusión; después de ello un total de 32 artículos conformaron la muestra final.
Resultados: considerando los objetivos planteados y los resultados obtenidos, se advierte que todas las acciones se enfocaban en tres instancias principales: a) formación y actualización para el desempeño del rol; b) factores predictores, facilitadores y barreras para ejercer el rol frente a una pandemia; y c) evidencia el rol frente a pandemias.
Conclusión: este estudio hizo posible conocer, tanto las barreras, como los aspectos facilitadores que permiten el cumplimiento del rol profesional de enfermería frente a pandemias o catástrofes. Además, dejo claro que las enfermedades infecciosas emergentes deben abordarse en forma inmediata, colaborativa y multidisciplinaria. La experiencia, el liderazgo y la formación profesional de enfermeras y enfermeros son atributos claves que estos profesionales poseen, para permitir que su rol sea más proactivo durante una situación de emergencia.

Palabras clave (Fuente DeCS): Rol de la enfermera; pandemias; enfermería en salud comunitaria; enfermeras clínicas; infecciones por coronavirus.

Resumo

Objetivo: analisar os fatores facilitadores e as barreiras para o cumprimento do papel profissional de enfermeiros e enfermeiras em tempos de pandemia e desastres.
Materiais e método: revisão integrativa segundo método analítico SALSA, realizada em oito bases de dados: Medline, Proquest, CINAHL, Web of Science, BVS, Sprin-gerLink, Scopus e PubMed. Os descritores utilizados foram: "papel da enfermeira" AND "pandemia" AND "paciente" AND "infecção por coronavírus", em inglês, espanhol e português. Aos 11 031 artigos encontrados, foram aplicados filtros e critérios de inclusão e exclusão. Depois disso, 32 artigos conformaram a amostra final.
Resultados: considerando os objetivos propostos e os resultados, constata-se que todas as ações se enfocavam em três instâncias principais: a) formação e atualização para o desempenho do papel; b) fatores preditores, facilitadores e barreiras para exercer o papel ante uma pandemia e c) evidência do papel profissional ante pandemias.
Conclusões: este estudo torna possível conhecer tanto as barreiras quanto os aspectos facilitadores que permitem o cumprimento do papel do profissional de enfermagem ante pandemias e catástrofes. Além disso, deixa claro que as doenças infecciosas emergentes devem ser abordadas de forma imediata, colaborativa e multidisciplinar. A experiência, a liderança e a formação profissional de enfermeiras e enfermeiros são atributos-chave desses profissionais para permitir que seu papel seja mais proativo durante uma emergência.

Palavras-chave (Fonte DeCS): Papel do profissional de enfermagem; pandemias; enfermagem em saúde comunitária; enfermeiras clínicas; infecções por coronavirus.

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.

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

Source: Own elaboration.

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).

Table 1. Distribution of studies by title, journal, impact factor, design, level of evidence, country, and year

Source: Own elaboration.

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.

Results regarding training and updating for the performance of the nursing role in the face of a pandemic

Following a thorough search, a number of 10 articles that demonstrated aspects of nursing education and updating of knowledge for the performance of the professional role in the face of a pandemic were described (Table 2).

Table 2. Studies that focused on the training and updating of knowledge for the performance of the role in the face of a pandemic.

Source: Own elaboration.

It can be noted that the objectives of the articles collected are focused on providing and updating the knowledge of nurses in the face of global health issues, including emerging infectious diseases, providing information on pandemics experienced by humanity such as the avian flu or the chaos in the face of a bioterrorist attack ⁽²⁷⁾; in addition, updating the knowledge in healthcare that the team and nurses could face in the event of a possible pandemic ^{(6, 25)}. It should be noted that the evidence recovered also reports new fields of action for nursing professionals regarding disaster preparedness; an example is the "forensic nursing" field ⁽²⁹⁾. However, although they have the basic competencies to deal with disasters, these professionals lack sufficient experience as well as adequate and specific preparation for disasters, which is evident in the lack of continuous training programs in this field ⁽⁴¹⁾. In this context, it is also suggested to promote the participation of palliative care in other fields of nursing in which it was not present, such as intensive care, with the aim of assisting nurses to provide care for the pain of patients and their families ⁽³⁷⁾. Another topic raised by the selected articles focuses on describing the experiences lived by students in the process of implementing curricula that address safe care and practices for patients and their families in the face of epidemics such as the HIV epidemic ⁽²³⁾, exploring, in addition, the understanding and interaction of political, social, and nursing actors in the event of a disaster ⁽³⁰⁾.

In light of the above, the results were conclusive regarding the existence of key strategies for the preventive preparation of nurses in the face of a catastrophe and/or epidemic, which corresponds to the training role of universities and nursing schools as an essential resource in the development of curricula, policies, practice guidelines, and simulation experiences; this would allow the development of skills, increase confidence and communication to face a potentially unsafe environment in order to provide care in personal and public health contexts. This innovation in education could also be extended to professionals currently working in this field, thus taking advantage of the knowledge they have acquired from previous disasters, their assessment skills, their ability to anticipate potential issues based on risk so that nursing professionals can play a proactive rather than a reactive role. It is necessary for nursing professionals to talk about and discuss this theme with their families and coworkers before a catastrophe happens, so that, when the time comes to make decisions, they are informed, also understanding that these professionals will face ethical dilemmas in the performance of their duties and that, simultaneously, they must face responsibilities regarding their families, the people they care for and their own health.

Finally, emerging global health issues should be viewed from a comprehensive and multidisciplinary perspective, under which nurses are the most suitable professionals to respond effectively since in their routine they are positioned in management, care, academic, and public health roles; with this experience, they are able to develop a creative and effective network to respond to an emerging health issue.

Results regarding predictors, enablers, and barriers in the exercise of the nursing role in a pandemic

From the totality of findings recovered in this research, this section describes the objectives and conclusions of 16 articles that demonstrate factors that predict, enable, and/or hinder the exercise of the role in the face of a pandemic (Table 3).

Table 3. Studies developed concerning predictors, enablers, and barriers to the performance of the nursing role in the face of a pandemic.

Source: Own elaboration.

In the selected evidence, the predictors, enablers, and barriers to the professional role of nurses can be noted. It is concluded that in order to maintain a nursing workforce in the face of a pandemic, there are predictors that should be considered to carry out this role, one of them being the need for support from local authorities and the community ⁽⁴²⁾, providing training in infection control and addressing the psychological needs of nursing professionals in the community, with the aim of increasing their willingness to care for patients during times of crisis ⁽¹⁴⁾.

On the other hand, the evidence also reports that there are enabling factors for the performance of the role, firstly, when it is considered that these professionals provide "constructive" support with their work ⁽³⁸⁾; in addition, they are resilient, capable of self-care and adaptability towards the continuous changes in protocol and scarcity of resources ⁽⁴²⁾, as well as their capacity for planning, support, information, active participation in research and adequate use of resources ⁽³⁹⁾, relevant aspects that should be considered by the employers of healthcare services, since they must ensure clear practices in the care to be provided, control measures for infections and personal protection equipment that is adequate for the use of healthcare providers, which are all indispensable variables to en­sure the health of healthcare providers and their families ⁽²⁸⁾; in addition, the need for psychological support for these professionals is also evident ⁽⁴⁸⁾, as well as the need for their continuing education. This need should not only satisfy nurses but also other healthcare providers who are for the implementation of programs and protocols with the objective of minimizing cross-infection for patient and staff safety in the face of a pandemic ^{(10, 33, 48)}, strengthening interdisciplinary work ⁽⁴⁶⁾. One strategy reported in this review that will undoubtedly support their performance in improving communication with isolated populations is telehealth.

Among the factors that hinder the performance of their role were the fear of working with patients with infectious diseases experienced by nursing professionals ⁽³²⁾ — and therefore, the need for support in case of contracting the disease ⁽⁴⁸⁾ —, the insecurity of not having adequate personal protective equipment ^{(46, 48)}, the fear of contam­inating members of their family, the social isolation that these profes­sionals must face ^{(3, 46)}, as well as the limited infrastructure and the deficit of nursing professionals ⁽³³⁾, the feeling of ignorance and underestimation of the efforts of nurses compared to physicians ⁽³⁸⁾, and the lack of social recognition ⁽⁴⁶⁾, all of which undoubtedly affect their willingness to work with and provide care for patients with infectious diseases ⁽²⁸⁾; in addition, the crucial contribution and work of immigrant nurses in support of the existing workforce is often overlooked, since despite the different nature and environment of their jobs, they can play a key role during times of crisis such as what has been witnessed in the COVID-19 pandemic ⁽³⁵⁾.

Finally, a study that unveils the reality of nursing in the Americas comments that, in order to have adequate nursing professionals, countries need to invest in improving their working conditions, ensuring the provision of personal protective equipment, and continuing education ⁽³⁶⁾.

Results found in the evidence dimension of the professional role in pandemics

Regarding the results found in the dimension 'evidence of the professional role in pandemics', nine articles were found. Their objectives and conclusions are detailed below (Table 4).

Table 4. Studies developed regarding role performance during pandemics and disasters

Source: Own elaboration.

Regarding the evidence on the role of nursing professionals in times of pandemic crisis, the first articles retrieved reported the role of American ⁽²⁶⁾ and African-American nurses in outbreaks such as the 1918 "Spanish flu" as a model of past pandemic experiences that occurred in periods of history with racial segregation and violence in which people of color were denied access to health, educational, and political institutions; nevertheless, these borderline situations that humanity experienced provided ephemeral opportunities for these professionals of color to deliver nursing care in response to public health emergencies ⁽³⁴⁾. Other articles have also demonstrated how nursing professionals coped with the formation of a lay nursing force without threatening their professional boundaries in times of pandemics.

As a consequence of the exposed results, it can be interpreted that nursing professionals in past pandemic experiences had a more reactive role, since, in the midst of pandemic crises, such as the AIDS crisis, for example, they promoted the interaction between community health nursing activities with individuals, families, and community, through the nursing process, managing to play diverse roles such as direct caregiver, advocate, case manager, health educator, program planner, program coordinator, which allowed these professionals to be considered agents of change ⁽²⁴⁾. Another role that was evident in the retrieved bibliography was the immediate reaction and cooperation of nursing professionals with the assistance of local community organizations in the face of a pandemic disease such as the influenza of 1918, since in the face of a shortage of supplies and medicines, and a rapid spread of the disease, "nursing home care" represented the only response and treatment that could be offered to the population in the midst of these crises ⁽²⁶⁾.

After a century, this same strategy was used again, bringing oncology care to patients' homes with the aim of minimizing the risk of infection in patients undergoing chemotherapy ⁽⁴⁹⁾. In a context of the low global availability of nursing professionals and the need for home care in the midst of the pandemic crisis, in the past it was necessary to consider the formation of a second line of lay or volunteer nurses in response to this need, with caution and keen avoidance of crossing professional boundaries regarding the basic instruction that non-professional nurses should receive; this consideration had to be taken into account, since in the future it could constitute a risk for the population to become dependent on these volunteers with precarious knowledge, in situations in which the nursing professionals became massively ill ⁽³¹⁾. Currently, the evidence reports some experiences that were necessary to address the need for care professionals; one of them was the need for a change of professional role that had to be experienced, for example, by nurse anesthetists, who used their experience, competencies, and skills in the management of the respiratory tract to contribute to the care of patients with pathologies derived from COVID-19 ⁽⁴⁰⁾. On the other hand, there was also an urgent need to improve bereavement counseling as a way of focusing attention not only on patients but also on their families ⁽⁴³⁾.

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.

Conflict of interests: none declared

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