Changing with the times

Author(s): Susan Trossman, RN

Specialty nurses adapt and deliver care during the pandemic.

As the world has shifted during the pandemic, so have specialty nursing practices—from rethinking how care is delivered to personal protective equipment (PPE) use. Additionally, nurses have increased their public outreach to quell the fears of people who need potentially life-saving care.

First, countering fear

  “People who are having chest pain or stroke-like symptoms are putting off care or thinking it’s not ‘bad enough,’ because they are afraid of contracting COVID-19 if they come into the emergency department [ED],” said Emergency Nurses Association (ENA) President Mike Hastings, MSN, RN, CEN.

This has become such an issue, particularly in areas where COVID-19 is surging, that ENA and the American College of Emergency Physicians (ACEP) launched a major media effort urging the public to not delay care for medical emergencies. According to an ACEP-Morning Consult poll, 80% of Americans said they are concerned about contracting COVID-19 from a healthcare facility, and almost one-third reported delaying care because of their concerns.

Hastings has witnessed this hesitancy firsthand. He recalled a man in his early 40s who was experiencing shortness of breath for several days before coming to the ED. The patient later died.

“Another patient had been passing blood through his stool for over a week,” said Hastings, a clinical manager of an ED in Washington state. “He knew it wasn’t normal, but he didn’t want to get sick [from COVID-19].” That delay in care ultimately led to the patient being admitted into the intensive care unit and undergoing blood transfusions.

Kim Newlin, MSN, ANP, FPCNA, president of the Preventive Cardiovascular Nurses Association, said people “doom-scrolling” on social media further fuels fears of interacting with healthcare systems. She said her facility and public health officials have engaged in community outreach emphasizing the importance of paying attention to heart attack and stroke symptoms, as well as ongoing efforts to prevent heart disease. Newlin, the director of cardiovascular services at a Northern California medical center, added that ignoring care for cardiovascular diseases, diabetes, obesity, and other conditions places people at higher risk for poor outcomes if they contract COVID-19.

In terms of other important care, oncology nurses have reported drop-offs in the number of people coming in for screenings, such as mammograms and colonoscopies, particularly as COVID-19 hit communities, according to Kathleen Wiley, MSN, RN, AOCNS, director of oncology nursing practice at the Oncology Nursing Society (ONS). “Nurses can play a huge role in helping the public feel confident and see the importance of keeping current with cancer screenings and surveillance where early-stage cancers can be diagnosed and addressed sooner,” she said.

Hastings added that the ENA-ACEP campaign also stressed that emergency nurses and other professionals are highly skilled at assessing COVID-19 patients and implementing measures to prevent the spread of infectious diseases.

Care delivery

When COVID-19 cases rose in her community, Newlin said the cardiac and pulmonary rehabilitation program she oversees closed from mid-March to mid-May and later briefly when another surge occurred after the Fourth of July holiday.

“We used our transitions in care process to see how we could connect with people through phone calls since we  don’t have a formal home-based rehab program,” Newlin said. “Our nursing team also called patients every week for health checks and to assess whether anyone needed to be seen in person.”

During that time, her team developed clinical guidelines to determine safe practices and patient selection criteria for when the onsite rehab program resumed. They decided patients who were highly motivated and were already doing well did not need to come in, nor did those over 70 years old unless they had clearance from their provider. Additionally, patients participating in the in-person program had to wear a mask, and fewer than 10 people, including staff, could be in the exercise room at one time; the facility limited overall capacity to 50%.

Although the cost of providing at-home rehab programs traditionally has not been reimbursed by Medicare, Newlin said that may change—and more quickly—because of their efficacy during the pandemic. That reimbursement could make rehab services available to people with transportation and other issues and lead to improved patient outcomes.

Looking more broadly, Newlin said cardiovascular nurses working in outpatient clinics and home health also are using telehealth and other technology to care for patients during the pandemic, and that practice trend most likely will continue, especially in remote areas.

Expanding with technology

Oncology nurses also have engaged in telehealth more widely as a way to minimize risk to cancer patients.

“Patients with cancer, who are more vulnerable to the serious effects of COVID-19, are anxious,” Wiley said. “So nurses have been providing a great deal of patient education virtually to calm fears and provide a way to stay in touch with cancer clinicians.

“Nurses also have been reassuring patients that their healthcare teams are making decisions through a risk-benefit lens,” she added. For example, certain treatments or surgeries may be able to be delayed. However, if onsite care can’t be delayed, oncology nurses are reinforcing the extra precautions that have been implemented—such as changes in waiting room policies and practices, and even the settings where infusions are administered.

“Based on their resources, cancer facilities have been getting creative with how they provide care, including one that provided infusions in a temporary outdoor clinic,” Wiley said.

Nurses specializing in hospice and palliative care have faced new challenges and created workarounds to meet the needs of patients and their families, as well.

When COVID-19 was surging in Illinois and highly restrictive visitor policies were in place, the biggest challenge was addressing the isolation that patients and their families were experiencing, according to Tricia Dziabis, BSN, RN, CHPN, who coordinates hospice services for inpatients and those being discharged from her hospital.

“We ramped up our secure telehealth videoconferencing and texting, and used iPads and other devices so patients and families could see each other,” said Dziabis, a Hospice and Palliative Nurses Association (HPNA) member. Further, COVID-19 presented a challenge to hospice nurses’ direct access to patients in some instances, including hospitalized patients who were infected with the virus, as well as hospice patients who were in nursing homes and other sites that limited outside providers.

“Because the hospital was trying to preserve PPE and ensure staff safety, the number of people who could go into patients’ hospital rooms was limited,” Dziabis said. “That made assessing needs more difficult because, as hospice nurses, we see things differently than those in acute care. So we needed bedside nurses to fully describe the symptoms they were witnessing in patients going through the dying process, and then teach them ways to alleviate distressing ones.” And hospice nurses in all settings had to get accustomed to donning additional PPE, using their voices and technology to comfort patients, and in some cases, managing ever-changing policies in certain settings, she said.

Additionally, many families of seriously ill or dying patients wanted them to come home with them instead of being discharged back to their assisted living or skilled nursing facilities, where visitor restrictions might be implemented. “Hospice nurses had to provide even more support to those patients and their family members, who were overwhelmed in their expanded care-giving role,” Dziabis said.

Other challenges

Holli Martinez, MSN, FNP-BC, ACHPN, FPCN, and other palliative care nurse practitioners at the University of Utah Hospital also initially struggled with changes in their daily practice as COVID-19 cases began increasing in June.

“Palliative nursing is high-touch, low-tech,” said Martinez, an
HPNA board member. “It’s about empathy and building rapport. When you’re wearing a PAPR [powered air-purifying respirator] and the patient has a mask on, there’s so much interference, from visual restrictions to noise levels. You try to read as much body language as you can from a safe space while having a serious discussion.”

As a result, Martinez said she relied more on video and phone conferencing to connect with patients and their families, some of whom were hundreds of miles away, to address patients’ needs and wishes and explain ways to best manage their condition.

“Suddenly, we had to shift to low-touch, high-tech care,” she noted. “Normally, pre-COVID, we would often have numerous family members surrounding a patient in the bed. Now, we have become more focused on making empathic connections with those we’re seeing on a screen. We’re taking more time to check in frequently with patients and families. I often say throughout a family meeting, ‘We have talked about a lot here and it can be tough on a call like this. Can we just check in to see how everyone is doing?’”

An additional challenge for the nurse practitioners on her team involved trying to honor the cultural traditions of the large number of COVID-19 patients who were transported from the Navajo Nation and Ute Tribe communities, she said. “We reached out to our palliative colleagues in New Mexico, who were able to give us in-time education on important cultural traditions and perspectives.”

While technology served as a critical tool during the pandemic, nurses described how difficult it was to have family members or friends unable to accompany patients for inpatient care.

“We normally want visitors engaged with us [in the ED],” Hastings said. “Visitors can provide detailed information to us and keep patients calm and occupied.”

And Wiley noted that oncology nurses have reported the impact of not having a dying patient’s support person in the room with them. “Oncology nurses are accustomed to death and dying,” Wiley said. “We’re also good at fostering communication and helping facilitate a good-bye. Doing that over Zoom has been difficult.”

Martinez noted that working with seriously ill patients in a health crisis can be emotionally draining, but COVID-19 has added “an extra layer of stress and an existential distress as patient and family suffering is often so high.” Additionally, some family members express their frustration as anger, such as with visitor policies, which also takes its toll on nurses.

PPE and other needs

One critical challenge for many nurses is access to PPE and its use.

ONS members have reported lacking access to the gowns and gloves they need to stay safe, given their need to handle chemotherapy drugs and other hazardous materials. Contributing to the PPE shortage for oncology nursing practice is the increased use of gowns and gloves by facility staff who routinely don’t require PPE in their roles, as well as the increased overall use of PPE.

Although emergency nurses are well-accustomed to using PPE, the constantly changing rules around its use were both confusing and troubling, Hastings said. This was particularly true when COVID-19 cases began to emerge in the Seattle area.

Earlier this summer, Hastings’ department implemented a new policy that requires emergency nurses to use eye protection with every patient encounter. Speaking globally, Hastings is worried about emergency nurses across the nation having enough PPE, as long as it continues to be used at such historically high levels. “I’m also concerned about having testing widely available and without delays,” he said.

Staffing-related issues also came into play as the pandemic surged and ebbed.

Wiley noted that based on COVID-19 activity, nurse navigators and advanced practice registered nurses who work on clinical trials also face challenges with where and when they work. Some are now deployed in new roles at cancer centers, while others are working from home or are furloughed.

Hastings added that in certain areas where COVID-19 activity is low, emergency nurses reported that they have been furloughed or have had their shifts canceled. At his ED, Hastings said they’ve gone from about 150 patients a day when COVID-19 cases were high, to seeing only 70 patients on a recent day. But the levels are unpredictable, making it difficult to be proactive with staffing, he said.

The pandemic also increased the need for more education and consults for providers and staff on communicating around palliative care and end-of-life issues. “Our country’s medical and nursing education system does not traditionally provide physicians and nurses the training they need to share serious news and to recommend a plan based on goals and priorities,” Martinez said. “But these skills can be taught and learned.”

Finally, Hastings offered this message: “This is really a marathon for us. The only way nurses are going to get through this is by working together.”

— Susan Trossman is a writer-editor at the  American Nurses Association.

Resources

Like many associations, the Oncology Nursing Society (ONS) has been offering nurses a wealth of specialty-focused resources on topics to help nurses since the pandemic began. Many of the topics ad- dress concerns raised by members through an ONS COVID-19 online community group. The Emergency Nurses Association has held virtual townhalls, offers a chat platform on pandemic concerns, and collaborates with the American Nurses Foundation to offer a range of self-care and mental well-being resources through the Well-being Initiative, along with the American Nurses Association, American Psychiatric Nurses Association, the American Association of Critical-Care Nurses and the Association of periOperative Registered Nurses. These specialty associations are organizational affiliates of ANA.

Emergency Nurses Association

Oncology Nursing Society

Preventive Cardiovascular Nurses Association

Hospice and Palliative Nurses Association

The Well-being Initiative

ANA Enterprise Covid-19 Resource Center

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