媒体和其他人强调了护士在整个大流行期间所做的重要且挽救生命的工作。英国首相鲍里斯·约翰逊（Boris Johnson）在大流行初期因 COVID-19 住院时，特别向护士们致敬，“他们在 [他] 床边站了 48 小时，而事情本来可能会朝着任何方向发展”
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Nurses are the largest healthcare workforce and have had direct, intense and sustained contact with COVID-19 patients throughout the pandemic playing an essential and frontline role in the COVID-19 response. Nurses have worked tirelessly and undertaken multiple roles during the pandemic including education, treatment, prevention, vaccination and research often in uncertain situations and to the detriment of their physical and mental health. They have also managed and cared for distressed patients and their families, and many have been redeployed to other roles often outside of their usual duties, all factors which have affected their well-being. They have publicly been lauded as ‘heroes’. Yet, their voices and perspectives are seldom heard or included in COVID-19 decision-making and in the development of interventions and responses at all levels from individual health services to national policymaking. Indeed, it has felt like these voices have been muted and excluded. Nurses' unique knowledge, expertise, needs and lived experiences are vital to the COVID-19 response. Without their inclusion, COVID-19 decision-making and initiatives are unlikely to be successful and patient outcomes poorer.
We work clinically and conduct nursing and health services research in several high-income countries (Australia, Denmark, Sweden and the United Kingdom) which have relatively high COVID-19 vaccination rates by world standards but have reported varying numbers of COVID-19 cases and deaths and implemented diverse responses to the pandemic. At the end of January 2022, the total confirmed COVID-19 deaths per million people in Australia and Denmark were below the world rate compared with higher rates in Sweden and the United Kingdom. Sweden has implemented fewer and less stringent restrictions than the other countries in which we work. The Swedish response was based on pragmatism, ‘common sense’ and personal responsibility. Schools and borders remained open, and no ‘lockdowns’ were implemented. In contrast, Australia, Denmark and the UK introduced many initiatives to limit or slow infection transmission. These included stringent ‘lock-downs, ‘social’ (physical) distancing, remote working for non-essential workers and remote learning for school-aged children and university students, the closure of international borders and restrictions to visitors in healthcare settings including hospitals and aged care. Additional income support was provided by government for those unable to work due to COVID restrictions. COVID-19 vaccinations for healthcare workers such as nurses were also mandatory in Australia. In the UK they were mandated for social care workers, but this requirement was dropped for NHS staff in early 2022.
Nevertheless, our research demonstrates the universal and considerable psychosocial impact of the COVID-19 pandemic on nurses internationally. About 20%–30% of the nurses we surveyed during the first wave of the pandemic reported mild to extremely severe psychological distress (Couper et al., 2021; Holton et al., 2020; Holton, Wynter, Rothmann, et al., 2021). Nurses also appear to have experienced greater psychological distress compared with other healthcare workers. Our study of hospital clinical staff conducted in Australia found that nurses and midwives were significantly more likely to experience symptoms of anxiety than doctors and allied health staff (Holton et al., 2020) and this association remained as the pandemic continued (Wynter et al., 2022). In Sweden, registered nurses reported more negative effects of the pandemic on their working conditions and ability to recover than other professional groups (Alexiou et al., 2021). This high level of psychological distress may have been exacerbated by reports of nurses dying due to COVID-19 estimated in October 2020 to be 1500 across 44 of the world's 195 countries (International Council of Nurses, 2020).
As well as high levels of psychological distress, the pandemic has also had a negative effect on nurses' work and personal lives. Nurses in all countries have reported concerns about contracting COVID-19, putting colleagues and family members at risk and caring for infected patients; the challenges of wearing and lack of access to personal protective equipment; the stress of being redeployed to other areas and undertaking different duties than normal; difficulties managing paid work and family responsibilities, including supporting children with remote learning; and experiencing moral distress when they are unable to deliver the care they wish to (Couper et al., 2021; Holton, Wynter, Trueman, et al., 2021).
The media and others have highlighted the important and life-saving work of nurses throughout the pandemic. Boris Johnson, the UK prime minister, paid special tribute to the nurses ‘who stood by [his] bedside for 48 h when things could have gone either way’ when he was hospitalized for COVID-19 early in the pandemic (Booth et al., 2020). In Denmark, Her Majesty Queen Margrethe II paid tribute to healthcare workers including nurses in her 2021 New Year's Address: ‘many people must again make an extra effort. This applies in particular to those who help trace and limit infection, and to those who treat the sick’ (HM The Queen of Denmark, 2021). In Sweden, nurses were recognized with ‘official national applause’ (as in the UK) and Swedish nurses received additional salary payments during different waves of the pandemic. Yet despite their raised profile, nurses' voices are seldom heard or considered in COVID-19 decision-making and responses.
Despite an increased positive focus in the media on nurses and their work during the pandemic, there are few instances of senior nurses sharing high level COVID-19 response information with the public or represented as leaders in COVID-19 decisions. Although chief health or medical officers have regularly attended government media briefings, chief nursing officers are seldom in attendance. For example, in Australia, Victoria's chief health officer, Professor Brett Sutton attended daily media conferences with the premier, Daniel Andrews, which were held for the first 19 months of the pandemic and provided updates about the number of COVID-19 deaths and cases, latest restrictions and decisions, and vaccination targets. Yet nurses have made limited appearances at these daily media conferences with the discussion mainly focused on their experiences of caring for COVID-19 patients or urging people to be vaccinated. England's chief medical officers were present at every briefing, yet the chief nurse only appeared twice at the daily briefings in 2020/21. In Denmark, the COVID-19 response has been managed by the Danish Health Authority and its director general, represented by medical professors in virology, epidemiology and infectious disease; not nursing.
Nurses have had limited representation in high level government and advisory group decision-making and planning about the COVID-19 response, particularly in comparison to members of the medical profession and public health experts and academics. The International Council of Nurses recently surveyed its 130-member national nursing associations (NNAs). Less than half of the NNAs reported that their government chief nurses had been involved in national health decision-making (41.5%) and similarly less than half of infection, prevention and control nurses (44.4%) or senior nurses (40%) had been involved in government decision-making about COVID-19 (International Council of Nurses, 2021).
Nurses in the UK have voiced concerns about their lack of involvement in key parliamentary discussions about protective personal equipment (PPE) and representation on official scientific advisory groups (e.g. SAGE) which provide advice to the government about COVID-19. A lack of nurses' voices was also evident in the establishment of the ‘Nightingale Hospitals’ in England during the first wave of the pandemic. Seven facilities were built at a total cost of £530 M and later all decommissioned with the exception of one, with very few patients ever admitted. Nurses' involvement in the decision to build these facilities appears to have been minimal although the Chief Nursing Officer for England did visit the London facility during its construction and opening. Staffing these facilities was problematic and calls were made in each National Health Service (NHS) region for volunteers from in existing nursing workforces; further stretching already strained and scarce resources.
There are some rare exceptions. In Denmark, the Danish Nurses Organization was invited to several working groups, meetings and negotiations to discuss the COVID response and workforce. Whilst in Australia, the Infection Control Expert Group which advises the Australian Health Protection Principal Committee on infection prevention and control including community transmission of COVID-19 is chaired by the Chief Nursing and Midwifery Officer and senior nurses are members. Nevertheless, the exclusion of nurses from decisions about the COVID-19 vaccine rollout in Australia has also been noted. Our recent study of Australian nursing and midwifery educators (Wynter et al., 2021) highlighted the lack of input that many nurses feel they have in COVID-19 decisions. One participant commented: ‘Feeling like things are being planned behind the scenes that will perhaps affect us but perhaps we're not included during the planning stages…’ (Wynter et al., 2021).
Our research in the UK identified that nurses frequently tried to raise concerns during the pandemic but an ‘organizational deafness’ existed which meant that their concerns were ignored (Adams et al., 2020). Many of the nurses we interviewed spoke about their moral distress at being ignored and silenced and some left the NHS as a result. One very senior nurse reflected on her experience of being redeployed to a national role during the pandemic. She stated that the government paused the interventions she had been involved in recommending and as a result, she stepped down from her role. She stated: ‘I didn't even get a thank you for what I'd done for, in the national [role]. It's never been acknowledged. So, I sent the emails that went to very senior people. I didn't get a response. Not even a reply’. Similar to other nurses we spoke to who did not hold such senior positions, she felt ignored and undervalued (Maben et al., under review).
As highly educated and skilled health professionals, who spend most time with patients and are critical to patient safety, it is vital that nurses have a voice in high level decisions about the response and planning for not only the COVID-19 pandemic, but also future health crises and adverse events. Nurses have unique healthcare expertise, intimate knowledge of healthcare systems, work in a variety of healthcare settings, are powerful patient advocates and have unique perspectives of patients' experiences. They need to be actively involved in the COVID-19 response, and response to other health challenges, to ensure effective decision-making, better patient outcomes, high quality and patient-centred care, and more robust healthcare systems.
We need to value and empower nurses, recognize the important role they play, and ensure their voices are heard and their recommendations are acted on, not ignored. To raise their voices, nurses need to work collaboratively to value, empower and learn from each other and take actions towards systematic organizational changes which includes nursing representation and leadership positions in healthcare settings, government advisory groups and committees; actively involving nurses in the development of health policy and practice similar to other groups of health professionals; appropriately supporting and resourcing the nursing workforce including education, recruitment, pay and working conditions; and providing appropriate and effective support for nurse well-being.
Nurses from different countries can learn from each other and strengthen their voices at individual, organizational and government levels. A unified, evidence-based nursing voice is critical and requires ongoing inclusive research at local, national and international levels.
Nurses around the world have made a considerable and valuable contribution at the point of care delivery during the COVID-19 pandemic, often at significant cost to their own psychological well-being and personal lives. Yet overwhelmingly they have had a limited voice in the national and regional responses to the COVID-19 pandemic in our respective countries. We believe nurses' can, and should, play an integral role in driving the conversation about the management of and response to the COVID-19 pandemic and other future adverse health events. A diversity of voices and expertise is critical for effective decision-making in times of crisis, benefitting collective action and ultimately patient care. It is time to make sure our mics are on and to turn up the volume!
全文翻译（仅供参考）
护士是最大的医疗保健人员，在整个大流行期间与 COVID-19 患者进行了直接、密切和持续的接触，在 COVID-19 应对中发挥着重要的前线作用。护士在大流行期间不知疲倦地工作并承担了多种角色，包括教育、治疗、预防、疫苗接种和研究，往往在不确定的情况下并损害他们的身心健康。他们还管理和照顾痛苦的患者及其家人，许多人经常被调往其他角色，这些角色往往超出了他们的日常职责，所有这些因素都影响了他们的幸福感。他们被公开称赞为“英雄”。然而，他们的声音和观点很少被听到或包含在 COVID-19 决策以及从个人卫生服务到国家决策的各个层面的干预措施和应对措施的制定中。事实上，感觉这些声音已经被静音和排除在外。护士独特的知识、专业知识、需求和生活经验对于应对 COVID-19 至关重要。如果没有他们的参与，COVID-19 的决策和举措就不太可能成功，患者的治疗效果也会更差。
我们在几个高收入国家（澳大利亚、丹麦、瑞典和英国）开展临床工作并开展护理和卫生服务研究，按照世界标准，这些国家的 COVID-19 疫苗接种率相对较高，但报告了不同数量的 COVID-19 病例和死亡人数，并对这一流行病采取了多种应对措施。到 2022 年 1 月末，与瑞典和英国的较高死亡率相比，澳大利亚和丹麦每百万人中确认的 COVID-19 死亡总数低于世界水平。与我们工作的其他国家相比，瑞典实施的限制越来越少。瑞典的反应是基于实用主义、“常识”和个人责任。学校和边界保持开放，没有实施“封锁”。相比之下，澳大利亚，丹麦和英国推出了许多限制或减缓感染传播的举措。这些措施包括严格的“封锁”、“社交”（物理）距离、非必要工人的远程工作以及学龄儿童和大学生的远程学习、国际边界的关闭以及包括医院和医疗机构在内的医疗机构对访客的限制。老年护理。政府为因 COVID 限制而无法工作的人提供了额外的收入支持。在澳大利亚，护士等医护人员也必须接种 COVID-19 疫苗。在英国，他们被要求为社会护理工作者提供服务，但在 2022 年初，对 NHS 工作人员的这一要求被取消。非必要工人的远程工作和学龄儿童和大学生的远程学习，国际边界的关闭以及对包括医院和老年护理在内的医疗机构的访客的限制。政府为因 COVID 限制而无法工作的人提供了额外的收入支持。在澳大利亚，护士等医护人员也必须接种 COVID-19 疫苗。在英国，他们被要求为社会护理工作者提供服务，但在 2022 年初，对 NHS 工作人员的这一要求被取消。非必要工人的远程工作和学龄儿童和大学生的远程学习，国际边界的关闭以及对包括医院和老年护理在内的医疗机构的访客的限制。政府为因 COVID 限制而无法工作的人提供了额外的收入支持。在澳大利亚，护士等医护人员也必须接种 COVID-19 疫苗。在英国，他们被要求为社会护理工作者提供服务，但在 2022 年初，对 NHS 工作人员的这一要求被取消。在澳大利亚，护士等医护人员也必须接种 COVID-19 疫苗。在英国，他们被要求为社会护理工作者提供服务，但在 2022 年初，对 NHS 工作人员的这一要求被取消。在澳大利亚，护士等医护人员也必须接种 COVID-19 疫苗。在英国，他们被要求为社会护理工作者提供服务，但在 2022 年初，对 NHS 工作人员的这一要求被取消。
尽管如此，我们的研究表明，COVID-19 大流行对国际护士产生了普遍而巨大的社会心理影响。在第一波大流行期间，我们调查的大约 20%–30% 的护士报告了轻度至极度严重的心理困扰（Couper 等人， 2021 年；Holton 等人， 2020 年；Holton、Wynter、Rothmann 等人， 2021 年）。与其他医护人员相比，护士似乎也经历了更大的心理困扰。我们在澳大利亚对医院临床人员进行的研究发现，护士和助产士比医生和专职医疗人员更容易出现焦虑症状（Holton et al., 2020)，并且随着大流行的继续，这种关联仍然存在（Wynter 等人， 2022 年）。在瑞典，注册护士报告说，与其他专业群体相比，大流行对他们的工作条件和恢复能力的负面影响更大（Alexiou 等人， 2021 年）。2020 年 10 月，全球 195 个国家中的 44 个国家中有 1500 名护士因 COVID-19 死亡的报告可能加剧了这种高度的心理困扰（国际护士理事会， 2020 年）。
除了高度的心理困扰外，这种流行病还对护士的工作和个人生活产生了负面影响。所有国家的护士都报告了对感染 COVID-19、使同事和家人处于危险之中以及照顾受感染患者的担忧；穿戴和无法使用个人防护设备的挑战；被调派到其他地区并承担与平时不同的职责的压力；难以管理有偿工作和家庭责任，包括支持儿童进行远程学习；当他们无法提供他们希望的护理时，他们会经历道德上的痛苦（Couper 等人， 2021 年；Holton，Wynter，Trueman 等人， 2021 年）。
媒体和其他人强调了护士在整个大流行期间所做的重要且挽救生命的工作。英国首相鲍里斯·约翰逊（Boris Johnson）在大流行初期因 COVID-19 住院时，特别向护士们致敬，“他们在 [他] 床边站了 48 小时，而事情本来可能会朝着任何方向发展”（Booth 等人。, 2020 年）。在丹麦，玛格丽特二世女王陛下在她的 2021 年新年致辞中向包括护士在内的医护人员致敬：“许多人必须再次付出额外的努力。” 这尤其适用于那些帮助追踪和限制感染的人，以及那些治疗病人的人”（丹麦女王陛下， 2021 年））。在瑞典，护士得到了“全国官方掌声”的认可（如在英国），瑞典护士在不同的大流行浪潮中获得了额外的工资。然而，尽管护士的形象有所提高，但在 COVID-19 决策和响应中却很少听到或考虑护士的声音。
尽管媒体对大流行期间护士及其工作的积极关注越来越多，但很少有高级护士与公众分享高水平的 COVID-19 响应信息或代表 COVID-19 决策的领导者。尽管首席卫生或医疗官定期出席政府媒体简报会，但首席护理官很少出席。例如，在澳大利亚，维多利亚州首席卫生官 Brett Sutton 教授与州长 Daniel Andrews 一起参加了在大流行的前 19 个月举行的每日媒体会议，并提供了有关 COVID-19 死亡人数和病例数的最新信息，最新的限制和决定，以及疫苗接种目标。然而，护士在这些每日媒体会议上的露面次数有限，讨论主要集中在他们照顾 COVID-19 患者或敦促人们接种疫苗的经历。英格兰的首席医疗官出席了每次简报会，但护士长在 2020/21 年度的每日简报会上只出现了两次。在丹麦，COVID-19 应对工作由丹麦卫生局及其总干事管理，由病毒学、流行病学和传染病医学教授代表；不是护理。COVID-19 应对工作由丹麦卫生局及其总干事管理，由病毒学、流行病学和传染病医学教授代表；不是护理。COVID-19 应对工作由丹麦卫生局及其总干事管理，由病毒学、流行病学和传染病医学教授代表；不是护理。
护士在高层政府和咨询小组关于 COVID-19 应对措施的决策和规划中的代表性有限，特别是与医学专业人士以及公共卫生专家和学者相比。国际护士理事会最近对其 130 个成员的国家护理协会 (NNAs) 进行了调查。不到一半的 NNA 报告其政府护士长参与了国家卫生决策（41.5%），同样不到一半的感染、预防和控制护士（44.4%）或高级护士（40%）参与了国家卫生决策。参与有关 COVID-19 的政府决策（国际护士理事会， 2021 年）。
英国的护士对他们缺乏参与有关个人防护装备 (PPE) 的关键议会讨论以及向政府提供有关 COVID-19 的建议的官方科学咨询小组（例如 SAGE）的代表表示担忧。在第一波大流行期间，英国“南丁格尔医院”的建立也明显缺乏护士的声音。7 个设施的建造总成本为 5.3 亿英镑，后来除一个外全部退役，很少有病人入院。尽管英格兰首席护士长在伦敦设施的建设和开放期间确实访问了伦敦设施，但护士参与建造这些设施的决定似乎很少。这些设施的人员配备是有问题的，每个国家卫生服务 (NHS) 地区都呼吁现有护理人员的志愿者；进一步拉伸已经紧张和稀缺的资源。
有一些罕见的例外。在丹麦，丹麦护士组织受邀参加多个工作组、会议和谈判，以讨论 COVID 应对措施和劳动力。在澳大利亚，就感染预防和控制（包括 COVID-19 的社区传播）向澳大利亚卫生保护主要委员会提供建议的感染控制专家组由首席护理和助产士担任主席，高级护士是成员。尽管如此，也有人注意到护士被排除在澳大利亚关于 COVID-19 疫苗推广的决定之外。我们最近对澳大利亚护理和助产士教育工作者的研究（Wynter 等人， 2021 年）强调了许多护士认为他们在 COVID-19 决策中缺乏投入。一位参与者评论说：“感觉像是正在幕后计划的事情可能会影响我们，但也许我们没有被包括在计划阶段……”（Wynter 等人， 2021 年）。
我们在英国的研究发现，护士在大流行期间经常试图提出担忧，但存在“组织耳聋”，这意味着他们的担忧被忽视了（Adams 等人， 2020 年）。我们采访的许多护士都谈到了他们在被忽视和沉默时的道德痛苦，一些人因此离开了 NHS。一位非常资深的护士回顾了她在大流行期间被重新部署到国家角色的经历。她说，政府暂停了她参与推荐的干预措施，因此她辞去了职务。她说：“在国家[角色]中，我什至没有感谢我所做的一切。它从来没有被承认过。所以，我把邮件发给了非常资深的人。我没有得到回应。甚至没有回复'。与我们交谈过的其他没有担任如此高级职位的护士类似，她感到被忽视和被低估（Maben 等人， 正在审查中）。
作为受过高等教育且技术娴熟的卫生专业人员，他们与患者相处的时间最多，对患者的安全至关重要，因此护士在高层决策中拥有发言权至关重要，这些决策不仅涉及 COVID-19 大流行，还涉及未来的应对和规划健康危机和不良事件。护士拥有独特的医疗保健专业知识、对医疗保健系统的深入了解、在各种医疗保健环境中工作、是强有力的患者倡导者并对患者的经历有独特的看法。他们需要积极参与 COVID-19 应对和其他健康挑战，以确保有效的决策、更好的患者结果、高质量和以患者为中心的护理以及更强大的医疗保健系统。
我们需要重视并赋予护士权力，认识到他们所扮演的重要角色，并确保听到他们的声音并采取行动而不是忽视他们的建议。为了提高他们的发言权，护士需要协同工作，重视、授权和相互学习，并采取行动实现系统的组织变革，包括在医疗机构、政府咨询小组和委员会中担任护士代表和领导职位；积极让护士参与制定与其他卫生专业人员群体类似的卫生政策和实践；为护理人员提供适当的支持和资源，包括教育、招聘、薪酬和工作条件；并为护士的健康提供适当和有效的支持。
来自不同国家的护士可以相互学习，并在个人、组织和政府层面加强他们的发言权。统一的、基于证据的护理声音至关重要，需要在地方、国家和国际层面进行持续的包容性研究。
在 COVID-19 大流行期间，世界各地的护士在提供护理时做出了巨大而宝贵的贡献，这通常会损害他们自己的心理健康和个人生活。然而，绝大多数情况下，他们在我们各自国家对 COVID-19 大流行的国家和地区反应中的发言权有限。我们相信护士可以而且应该在推动有关管理和应对 COVID-19 大流行和其他未来不良健康事件的对话中发挥不可或缺的作用。多样化的声音和专业知识对于危机时期的有效决策、集体行动以及最终的患者护理至关重要。是时候确保我们的麦克风已打开并调高音量了
原文链接：
https://onlinelibrary.wiley.com/doi/10.1111/jan.15236
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