New Research on Healthcare Protocol Adherence during COVID-19 from Grafova

January 16, 2024

Voices from frontline nurses on care quality and patient safety during COVID-19: An application of the Donabedian model


  • The majority of RNs reported that staffing ratios impacted adherence to safety protocols during the first wave of the COVID-19 pandemic.

  • Organizational factors, including staffing and resources, hindered protocol adherence.

  • Inadequate staffing and high patient acuity linked to adverse patient and staff outcomes.


The COVID-19 pandemic has adversely impacted quality of care and patient safety. This study aimed to describe registered nurses’ (RNs) perceptions on the impact of the COVID-19 pandemic on their ability to adhere to patient safety protocols using Donabedian’s Health Care Quality model.


In October 2020, a survey was conducted among all actively licensed RNs in New Jersey who provided direct patient care during the first peak of COVID-19.


Of 3,027 participants, 68% reported that the number of patients assigned impacted their ability to adhere to protocols. RNs identified a variety of organizational structures impacting adherence, including inadequate staffing, staff qualifications, and inadequate resources. Impacted processes included the inability to adhere to patient safety protocols and conduct comprehensive assessments and surveillance, the need for additional time spent on personal protective equipment and isolation policies, and difficulty maintaining isolation integrity; the need to prioritize and cluster care; and guidelines limiting personnel who could enter the room. Nurses attributed both adverse patient and staff outcomes to inadequate staffing and high patient acuity.


These findings highlight the need for health care organizations to support frontline nursing staff in adhering to patient safety and infection prevention and control protocols during times of crises. Infection preventionists have substantial contact with bedside nurses and should leverage their collegial relationships to promote patient safety.

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Monika Pogorzelska-Maziarz, Pamela B. de Cordova, Mary Lou Manning, Mary L. Johansen, Irina Grafova, Angela Gerolamo, Voices from frontline nurses on care quality and patient safety during COVID-19: An application of the Donabedian model, American Journal of Infection Control, Volume 51, Issue 12, 2023, Pages 1295-1301, ISSN 0196-6553,

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