Federico D’Urso 1*, Salvatore Trifiletti 2, Edoardo Falcone 1, Mara Gracy Basile 1, Ulrico Angeloni 1
1. Public Health Unit, Italian Red Cross – National Headquarters, 00151, Rome, Italy
2. Department of Medical, Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, University of Catania, 95125, Catania, Italy.
* Corresponding author: Federico D’Urso, Public Health Unit, Italian Red Cross – National Headquarters, 00151, Rome, Italy. E-mail: federico.durso@gmail.com
Cite this article
ABSTRACT
Introduction: Biocontainment transfer represents a complex and delicate phase of care, especially in light of the increased demand for safe handling of patients affected by highly transmissible diseases. The COVID-19 pandemic has highlighted the critical need for structured approaches to ensure quality care and safety during these transfers.
Objective: To propose a structured nursing model for managing the care of conscious and communicative patients undergoing biocontainment transport, based on nursing diagnoses and standardized interventions.
Methods: A theoretical-conceptual model was developed based on the NANDA-I 2024–2026 taxonomy to identify nursing diagnoses related to perception, cognition, and stress tolerance. These were systematically combined with appropriate interventions from the Nursing Interventions Classification (NIC) and expected outcomes from the Nursing Outcomes Classification (NOC). The model addresses the clinical and psychological needs of patient across the three phases of transport: pre-transport, transport, and post-transport, with particular focus on anxiety management, communication, and adaptation to isolation.
Results: In the pre-transport phase, the diagnosis of Excessive Anxiety was addressed with interventions to reduce emotional distress and improve patient cooperation through clear, empathetic communication. During transport, the impairment of verbal communication caused by protective equipment and isolation barriers was mitigated through simplified language, visual aids, and strategies to ensure mutual understanding. In the post-transport phase, the model focused on enhancing the patient’s coping capacity and resilience, offering emotional support and structured interventions to manage stress and process the experience.
Conclusions: The proposed model provides a comprehensive and systematic framework for nursing care during biocontainment transfers, integrating both clinical and emotional aspects to reduce patient vulnerability and improve the quality of care. As a theoretical model built upon standardized nursing taxonomies, it lays the groundwork for future clinical applications. Prospective and pilot studies will be essential to validate its effectiveness and feasibility in real-world healthcare settings.
Keywords: Biocontainment, Biocontainment patient transport, Nursing process, Clinical complexity, Advanced nursing practice.
INTRODUCTION
The current healthcare landscape has changed radically compared to a few years ago; the COVID-19 pandemic has highlighted structural and staffing shortages on a global scale [1,2]. The increase in the number of patients affected by highly transmissible diseases requiring high-intensity care has led to the widespread introduction of isolation devices that were once reserved for extremely rare situations. Biocontainment isolators have proven to be essential in the transport of these patients and typically include a protective plastic enclosure, a High Efficiency Particulate Air (HEPA) filter that removes harmful airborne particles, and a ventilation system that maintains a clean airflow at controlled pressure, preventing the escape of pathogens [2].
In the presence of diseases characterized by a high risk of mortality or a lack of appropriate preventive measures and effective treatments, the use of isolators becomes essential to ensure maximum safety for both the patient and healthcare personnel [1,3,4].
Preparing and managing the patient for a biocontainment transfer represents one of the most complex challenges for healthcare personnel, requiring protocols and technologies to guarantee both staff protection and the quality of patient care [2].
The use of biocontainment isolators can be compared to a form of physical restraint, as they impose an isolation measure that limits the patient’s interaction with the external environment [5].
Although biocontainment isolators are essential for the safe transport of patients, their implementation presents significant logistical and organizational challenges that must be addressed [1,2].
Several studies have addressed the logistical and clinical challenges associated with the transport of patients in high-level containment. Gibbs et al. (2019) provide a comprehensive review of air medical evacuation protocols for biocontainment transport, focusing on technical and operational safety measures [1]. Similarly, Corradi et al. (2021) assess the public health implications of biocontainment systems used in ambulances, while D’Urso et al. (2024) describe possible care protocols for patients transferred using a biocontainment stretcher [2,6]. However, these contributions primarily emphasize technical configurations and infection control, without proposing a structured model of nursing care.
Studies investigating patient management within dedicated biocontainment units (e.g., Flinn et al., 2021) and during pandemic conditions Rehn et al., 2023 have highlighted the complexity of delivering safe care in isolation, yet they stop short of defining a standardized nursing process [3,7]. Other investigations have explored the communicative and emotional needs of patients in constrained settings. For example, the impact of personal protective equipment (PPE) on communication is well documented (Aengst et al., 2022; Saunders et al., 2021), and the relevance of augmentative and alternative communication (AAC) strategies in ICUs has been addressed by Costello (2000) and Zaylskie et al. (2024) [5,8-10]. Ten Hoorn et al. (2016) offer a systematic review on communication with mechanically ventilated patients, further supporting the need for dedicated relational strategies in high-complexity care [11].
While these studies help define the relational and contextual challenges of care in isolation, they do not translate into a structured, taxonomy-based model. Beam et al. (2010) and Swickard et al. (2014), for example, offer insights into the organization of biocontainment units and interfacility critical care transport, but without applying NANDA-I, NIC, or NOC frameworks [12,13].
This overview of the current literature confirms the absence of validated nursing care models specifically designed for conscious and communicative patients undergoing biocontainment transfers, thereby justifying the development of a structured approach grounded in standardized nursing taxonomies.
To fill this gap and address these challenges, the development of a structured nursing care model, based on targeted nursing diagnoses, is essential to guide clinical practice. Such a model can improve patient safety, enhance the quality of communication, and ensure continuity of care throughout the different phases biocontainment transfer process [6,7].
Objective and purpose
The aim of this study is to develop and propose an innovative structured nursing model designed to address both the clinical and psychological needs of conscious and communicative patients undergoing biocontainment transport. The model integrates standardized nursing diagnoses, interventions, and outcomes to enhance communication, reduce anxiety, and improve overall patient care across all phases of transport, laying the foundation for future clinical validation.
DEVELOPMENT OF THE CARE MODEL
Sampling and Eligibility
This study consists of a theoretical and methodological proposal for a structured care model for conscious and communicative patients without the actual collection of clinical data.
The model is designed for future applications in clinical practice and is intended to be validated in prospective studies involving real patients and healthcare teams.
Instruments
The care model is based on the integration of nursing diagnoses (NDs) from the NANDA-I 2024–2026 taxonomy and integrates elements from the NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) systems. The selection of nursing diagnoses, interventions, and outcomes was informed by a narrative review of literature related to care in isolation, high-risk transport, and psychological support in confined environments. Due to the absence of specific scientific studies on biocontainment transfers, references from similar contexts were used. The process was further refined through structured consensus among the authors, all of whom have experience in emergency nursing and biocontainment patient management. To correctly select the appropriate NDs, an in-depth analysis was conducted of all thirteen domains included in the NANDA-I 2024–2026 classification. Some domains were excluded from consideration for the biocontainment transfer of conscious and communicative patients, as they were not relevant to the specific context. Domain 1 (Health Promotion) was excluded due to its focus on long-term behavioral patterns, domains 2 (Nutrition) and 3 (Elimination and Exchange) were not considered since they are not typically involved in short-term transfers and are managed in longer-duration ones. Domain 4 (Activity/Rest) was excluded because of its limited relevance during transport. Domains 6 (Self-Perception), 7 (Role Relationships), 8 (Sexuality) and 10 (Life Principles) were deemed not pertinent to biocontainment transfer. Furthermore, the domains 12 (Comfort) and 13 (Growth/Development) were excluded because they are not central in urgent care situations.
Domain 11 (Safety/Protection), although potentially relevant from a clinical standpoint, was excluded because it primarily focuses on physical risks such as infections or trauma. The typical patient considered is already in a similar condition; however, the main goal of the proposed model is instead to enhance the communicative, relational, and emotional dimensions of care through structured nursing interventions. Given these factors, the analysis focused on two specific domains the domain 5, (Perception/Cognition) with particular attention to cognitive understanding and communication and domain 9 (Coping/Stress Tolerance), which addresses psychological and emotional reactions. Within domain 5, only class 5 (Communication) was retained, as it includes diagnoses that are directly applicable to the needs of conscious patients experiencing communication difficulties due to the constraints of the biocontainment context, including the use of PPE. The other classes within this domain class 1 (Attention), 2 (Orientation) and 3 (Sensation/Perception), were excluded as they currently contain no NDs. Class 4 (Cognition) was also excluded, as it refers to cognitive deficits that require specific clinical and pharmacological management. In the case of a disoriented patient placed in a biocontainment isolator, such a condition would likely be exacerbated by the restrictive environment, making sedation the most appropriate and safe option for transport. Regarding domain 9, only class 2 (Emotional Responses) was included, as it encompasses diagnoses such as anxiety, ineffective coping, and stress responses, which are frequently observed in patients subjected to restrictive isolation. The remaining classes, 1 (Post-Trauma Responses) and 3 (Impulse Control), were excluded. In particular, class 1 was deliberately not considered, as the aim of the proposed model is to prevent the onset of post-traumatic stress symptoms related to the biocontainment transfer, by supporting the patient through structured interventions that reduce emotional overload and promote coping during the procedure. Based on this taxonomic analysis, the nursing care model was structured into three distinct phases, pre-transport, transport, and post-transport, each associated with specific nursing diagnoses, related interventions, and expected outcomes.
Pre-transport phase
The lack of knowledge about the biocontainment stretcher and the procedures to be carried out during the transfer generates, at this stage, significant emotional distress and anticipatory anxiety. The nursing diagnosis excessive anxiety (00400), classified under domain 9, class 2, was selected based on observations conducted in clinical practice, where behavioral and physiological signs such as agitation, increased heart rate, and verbal expressions of concern are commonly noted.
Other diagnoses within the same class, such as fear (00390) or impaired resilience (00210), were excluded because they involve long-term patterns or cannot be adequately documented within the limited timeframe of the transfer.
To address this diagnosis, the NIC interventions anxiety reduction (5820) and emotional support (5270) were selected, with the expected NOC outcome being anxiety Self-Control (1402). [14]
Since the goal of this care model is to promote coping, we preferred to use the NOC Anxiety Self-Control (1402), as it reflects the objective of enhancing the patient’s conscious management of anxiety.
The NOC Anxiety Level (1211) may be useful for an initial clinical assessment or for pre-post comparisons, but its purpose would remain limited to quantifying the symptom.
In this phase, it may be useful to conduct an initial assessment of the patient’s anxiety level, followed by a second evaluation to measure the effectiveness of interventions, using a rapid-assessment tool such as the Generalized Anxiety Disorder-7 (GAD-7) scale [15,16].
Transport phase
The use of the biocontainment stretcher and PPE generates significant communication barriers between patients and healthcare professionals. Within domain 5, class 5 of the NANDA-I taxonomy, the diagnosis Readiness for Enhanced Communication (00185) was excluded, as it is focused on strengthening a communicative process that is already functioning. In this context, however, it is necessary to implement an alternative communication system to replace the traditional one, which is compromised by operational conditions.
Similarly, the diagnosis Risk for Impaired Verbal Communication (00434) was excluded because it refers to a susceptibility to communication impairment, whereas in the current scenario the impairment is already present.
The most consistent was found to be DN Impaired Verbal Communication (00051), which characterizes a limited or nonexistent capacity for verbal communication. [9,10] The selected nursing interventions are Communication Enhancement: Speech Deficit (4976) chosen to facilitate effective information exchange through alternative communicative methods during the transport phase.
Communication (0902), the related NOC, enables the assessment of the efficacy of the patient-provider relationship in situations where communication is constrained.
Post-transport phase
In this phase, the patient faces the need for emotional recovery and coping support following the biocontainment transfer, the DNs Readiness for Enhanced Coping (00158), classified under domain 9, class 2, was selected, as it reflects the patient’s willingness and potential to strengthen adaptive strategies in response to an acute stress situation [14,16].
This choice is based on the authors’ clinical observations in most cases; conscious and cooperative patients exhibit transient emotional discomfort that can be interpreted as a normal physiological response to stress rather than a failure of their coping abilities. Consequently, diagnoses such as Ineffective Coping (00069) were excluded, as they would imply a dysfunction in stress management and risk labeling a temporary and reactive experience as a psychological disorder.
The care objective is not the treatment of a psychological condition, but rather the enhancement of the patient’s existing personal resources by fostering resilience and facilitating the emotional processing of the experience through structured interventions.
In line with this approach, several standardized nursing interventions (NIC) were selected to support the patient’s adaptation and increase their stress management capacity. Among them, Coping Enhancement (5230) represents the core intervention aimed at promoting an adaptive response to the experience.
These are supported by Emotional Support (5270) which is essential for normalizing emotional reactions, containing residual anxiety, and facilitating emotional rebalancing.
Relational interventions such as Active Listening (NIC 4920) and Counseling (NIC 5240) complete the care plan by allowing for deeper processing of the experience and fostering continuity in the nurse–patient relationship beyond the acute phase.
The expected outcomes identified are Coping (NOC 1302), Personal Resiliency (NOC 1309) and Anxiety control (NOC 1402) as they allow for the systematic evaluation of the patient’s adaptive process and the effectiveness of the nursing support provided during the recovery phase.
To assess coping strategies, the Brief COPE Inventory scale may be used, [17] while the Connor-Davidson Resilience Scale (CD-RISC), including the short form (CD-RISC-10), could be adopted to measure the ability to recover from adverse events, potentially establishing a proper follow-up for the patient [18].
The effectiveness of the proposed nursing interventions can be evaluated through a combination of NOC indicators (e.g., Anxiety Self-Control, Communication, Coping), behavioral observations, and, when applicable, validated psychological scales such as the State-Trait Anxiety Inventory (STAI-Y) or Hospital Anxiety and Depression Scale (HADS) [19,20].
The model was developed through a review of literature from related care contexts (e.g., intensive care units, isolation wards) and the consensus among the authors, formed during recent the COVID-19 pandemic. These choices provide a foundation for guiding future empirical validation and pilot implementation.
Statistical Analysis
As this work presents a theoretical nursing care model and does not involve the collection of quantitative data, no statistical analysis was performed. Future prospective studies, involving structured data collection and patient outcomes measurement, will be necessary to validate the proposed model using appropriate statistical methods.
DESCRIPTION OF THE PROPOSED MODEL
In biocontainment transfers, three distinct phases of nursing care can be identified: the preparatory phase before transport (pre-transport), the transfer phase using the isolator (transport), and the final phase after transport (post-transport). Each phase presents specific care and assistance needs.
Before transport, the patient may experience excessive anxiety related to the procedures and the outcome of the transfer, also due to the visual impact of the isolator. Its limited space may cause a sense of claustrophobia, further intensifying the level of distress.
The observation of specific defining characteristics, such as behavioral/emotional signs like anguish, psychomotor agitation, and verbalized fears, as well as physiological signs like increased heart rate and blood pressure, facial flushing, and a trembling voice, suggests a state of disproportionate and persistent concern in response to perceived threats. Based on these elements, the most appropriate nursing diagnosis is Excessive Anxiety (00400), as it accurately reflects the patient’s distress, expressed through both emotional and behavioral signs and physical hyperactivation.
The primary goal becomes Anxiety Self-Control (NOC 1402), assessed through a reduction in agitation and increased patient cooperation. To achieve this, targeted interventions are necessary. Anxiety Reduction (NIC 5820) and Emotional Support (NIC 5270) are essential to create a reassuring environment and foster empathetic communication.
During biocontainment transport, the use of PPE and the isolator may create concrete communication barriers, [3,5,8] resulting in frustration or misunderstanding. This scenario corresponds to the diagnosis Impaired Verbal Communication (00051), characterized by limited or absent ability to receive, process, transmit, and/or use a symbol system. The outcome to be achieved is Communication (NOC 0902).
The intervention plan includes a key nursing intervention, the Communication Enhancement: Speech Deficit (NIC 4976), which encourages the use of alternative communication channels (e.g., visual aids) and promotes the use of shared language, ensuring mutual understanding.
Concrete examples include:
Use of visual aids such as augmentative and alternative communication (AAC) boards, [9] shared with the patient during the pre-transport phase, or tablets/whiteboards to facilitate needs expression.
Active listening techniques: maintaining eye contact, nodding, asking clarifying questions, allowing time for patient responses [11].
Frequent comprehension checks: asking the patient to repeat or rephrase the information received to confirm understanding.
By implementing these strategies, nurses support patients in overcoming communication barriers related to PPE, isolators, and other devices, maintaining an effective and safe level of interaction.
In the post-transport phase, the need to strengthen coping strategies becomes particularly evident when the patient shows difficulty processing the experience or managing stress from isolation. In this context, the diagnosis Readiness for Enhanced Coping (00158) describes the possibility of reinforcing cognitive and/or behavioral efforts to deal with distressing situations.
The expected outcomes (NOC) include Coping (1302), Personal Resiliency (1309), and Anxiety Self-Control (1402). The aim is to increase the patient’s ability to manage stressful events, [21] show flexibility in new circumstances, and limit agitation or irritability.
Several key interventions (NIC) support this goal:
Coping Enhancement (5230), which encourages identification of existing strategies and discovery of additional resources (e.g., family support via video call, mindfulness techniques) [14].
Emotional Support (5270), offering empathetic listening and normalization of stress reactions [22].
Active Listening (4920) and Counseling (5240), which aid in processing the experience, reduce frustration, and foster patient cooperation [22-24].
Counseling (5240) supports the patient in processing emotional distress by fostering a trusting, empathetic relationship. It helps the patient identify sources of discomfort, express concerns, and explore adaptive coping strategies, thereby enhancing self-awareness and emotional stability after the transfer process [18,22].
PhaseDiagnosis (Code)DomainClass
| Phase | Diagnosis (Code) | Domain | Class | NIC | NOC |
| Pre-transport | Excessive Anxiety (00400) | 9 | 2 | Anxiety Reduction (NIC 5820) | Anxiety Self-Control (NOC 1402) |
| Emotional Support (NIC 5270) | |||||
| Transport | Impaired Verbal Communication (00051) | 5 | 5 | Communication Enhancement: Speech Deficit (NIC 4976) | Communication (NOC 0902) |
| Post-transport | Readiness for Enhanced Coping (00158) | 9 | 2 | Coping Enhancement (NIC 5230) | Coping (NOC 1302) Personal Resiliency (NOC 1309) Anxiety Self-Control (NOC 1402) |
| Emotional Support (NIC 5270) | |||||
| Active Listening (NIC 4920) | |||||
| Counseling (NIC 5240) |
Table 1. Association between the phases of biocontainment transport and the related elements of the nursing process.
Table 2 illustrates the functionality and operational implementation of the proposed model across the three phases of biocontainment transfer. That table presents a structured fictitious clinical case; for each phase, it describes a generic patient scenario along with the corresponding nursing interventions. This approach aims to exemplify how the theoretical model can be translated into clinical practice, promoting its reproducibility and applicability in high-complexity care settings.
| Phase | Fictitious Case Description | Practical Nursing Interventions |
| Pre-transport | A conscious and oriented adult patient is informed of an imminent transfer toward the radiology department using a biocontainment stretcher. Upon seeing the isolator, the patient becomes visibly agitated, expresses fear, and shows signs of anxiety (e.g., flushed face, tachycardia). | • Apply Anxiety Reduction (NIC 5820) • Use Emotional Support (NIC 5270) • Perform a rapid anxiety screening (GAD-7) • Introduce the AAC board |
| Transport | During transfer, communication is significantly impaired due to PPE and physical barriers. |
|
| Post-transport | After reaching the destination, the patient expresses emotional exhaustion and stress. |
|
Table 2. Fictitious clinical case illustrating nursing interventions across the phases of biocontainment transport.
Figure 1. Conceptual flowchart illustrating nursing diagnoses, interventions (NIC), outcomes (NOC), assessment tools and practical applications across the phases of biocontainment transport.
DISCUSSION
The aim of this study is to develop and propose an innovative structured nursing model designed to address both the clinical and psychological needs of conscious and communicative patients undergoing biocontainment transport. As mentioned in the introduction, most of the literature currently published focuses on the organizational, logistical and technological aspects of the transfer to biocontainment rather than offering organized and systematic nursing care models. Since it incorporates nursing diagnoses, interventions, and expected outcomes based on the NANDA-I, NIC, and NOC taxonomies, the model offered here represents an original contribution in this context. It provides a theoretical and practical approach focused on the psychological, communicative, and relational needs of conscious and communicative patients throughout the entire transfer process. This model is a novel idea that can be validated and applied in high-complexity care settings because of its attention to care detail, taxonomic clarity, and clinical application. The structured model developed highlights how each phase of biocontainment transfer presents specific and distinct care needs. The systematic approach to managing pre-transfer anxiety, maintaining effective communication during transport, and providing psychological support after transfer underscores the need for personalized and coordinated interventions.
The integration of nursing diagnoses, NOC outcomes, and NIC interventions enables the construction of a comprehensive care response that addresses not only clinical aspects but also emotional and relational dimensions.
The impact of biocontainment on patient-provider communication is particularly significant [3,5].
The use of PPE and isolating devices presents real obstacles and requires well-planned alternative strategies to prevent further emotional deterioration.
Finally, the post-transport phase is often underestimated but can be a critical moment for the patient to process the experience. Strengthening coping skills and promoting resilience not only improve clinical outcomes but also enhance the patient’s overall care experience [21].
Limitation
This theoretical nursing care model was developed through the integration of taxonomy and expert consensus, without direct patient involvement.
The implementation and effectiveness in real clinical settings have not yet been evaluated; future studies should be structured to assess the outcomes related to its application through quantitative measurements and subsequent evaluations in biocontainment transfer settings.
Such investigations will be essential to refine the model and confirm its clinical relevance and utility.
The proposed nursing care model can be practically applied in various high-complexity clinical settings, such as infectious disease units, intensive care units, and specialized medical transport services for highly infectious patients.
To validate the model’s effectiveness, the systematic collection of clinical data before and after the biocontainment transfer is recommended. Among the possible assessment tools, the GAD-7 scale may be used for anxiety, the Brief COPE Inventory for coping strategies, and the CD-RISC-10 for resilience levels. In cases of limited verbal communication, the use of structured observational checklists and AAC (Augmentative and Alternative Communication) tools can provide reliable alternative measurements.
The analysis of collected data may include descriptive statistics and inferential tests to compare pre- and post-intervention conditions. These strategies will allow for measuring the model’s impact on key care outcomes and refining its applicability for potential structured implementation in the future.
CONCLUSIONS
The management of patients in biocontainment requires a strategic combination of clinical and communication skills to address the nursing diagnoses that emerge throughout the three phases of transfer. By applying structured care models, it is possible to improve clinical outcomes, reduce biological risks, and ensure effective communication even in extreme isolation conditions. The integration of protocols and nursing interventions provides an effective solution to the demands of complex and highly specialized care. Although the efficiency of the suggested model has not yet been confirmed in practical situations, it constitutes a substantial theoretical advance to the nursing management of biocontainment transfers. In order to confirm its practical application and quantify its observable advantages on important care outcomes, pilot projects and prospective studies should be started and carried out in real care situations. The model’s robustness can only be verified and its organized adoption encouraged by means of rigorous testing
Ethical Approval
For this study, no formal approval from the Local Ethics Committee was required.
Conflicts of Interest and Funding Sources
The authors declare that they have no conflicts of interest related to this work. The study received no financial support from public or private entities, including pharmaceutical or industrial companies.
Authors’ Contributions
Federico D’Urso: conceived the study, developed the care model, and coordinated the writing of the manuscript. Salvatore Trifiletti: contributed to the organization of the NANDA-I, NIC, and NOC framework. Edoardo Falcone: participated in literature review and content refinement. Mara Gracy Basile: contributed to methodological structure and theoretical validation. Ulrico Angeloni: revised and validated the entire study and ensured its clinical and theoretical consistency. All authors read and approved the final version of the manuscript.
Acknowledgments
The authors would like to thank the staff of the Italian Red Cross – Public Health Department for their continuous support and collaboration in developing the proposed model. Special thanks also to the academic community for the critical reflection that inspired the elaboration of this work.
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