Lessons from COVID

Abstract

It is with great humility and overwhelming respect for our frontline nursing colleagues around the world that we share this reflection on what we have learned about the importance of delivering fundamental nursing care in a time of COVID. We are writing and reflecting from privileged positions: AK is living in Australia, which so far has not endured the operational challenges of dealing with ongoing volumes of very sick patients with COVID; AM and GH in Sweden and the Netherlands, respectively, have come face-to-face with the frontline challenges working in emergency departments (EDs) and COVID wards. But they also can retreat to less confronting and dangerous work roles in their research and academic positions just as AK can. We are all signatories to the Aalborg Statement (Kitson et al. 2019), which literally 3 months before COVID took hold of the world was encouraging health systems to revalue and rethink the importance of fundamental care to people's well-being and health. As COVID unfolded, we were reminded of the importance of handwashing and social distancing as premier infection control measures; we were less confident about the efficacy of face masks; but as time went on, we all began to acknowledge that where medications and vaccines failed, it was left to armies of nurses at the frontline to keep patients alive by diligently, painstakingly and courageously tending to patients’ fundamental care needs such as breathing, turning, personal hygiene, eating and drinking and stopping deconditioning. Indeed, amidst the multiple and continuous stream of images of people coping with COVID that have bombarded our TV screens was an image of six PPE clad nurses together turning a patient on an ICU bed. The reporter's comment was that the (only) thing health professionals could do to care for this patient was to turn him to help his breathing. There was no cure, and we, as health professionals, were reduced to offering basic (but labour-intensive) care. The inference was that medical science had let us down and that what we were left with was labour-intensive, expensive, risky and at times futile care. In the face of these stories and experiences have we moved on from the need to promote how we value, resource and deliver person-centred fundamental care? And what can our experiences of caring for patients with COVID and families teach us about the importance of getting fundamental care right for our health and care systems in the future? In preparing this editorial, we reflected on our different experiences of trying to understand what delivering person-centred fundamental care means in a time of COVID. From this, we have identified several consistent themes that have come through in our work and which also affirm what we ought to be embracing as significant reform in a post-COVID, vaccine-safe world (until the next pandemic). We share these reflections to start (or continue) the debate so that we can create the momentum for person-centred fundamental care reform across our health and care systems. We also want our observations to lead to practical improvements to the way that nurses are cared for and supported by and in their workplaces. And whilst our focus is on nurses, we acknowledge that every other member of the healthcare team will have similar needs but possibly not to the depth and extend of nurses who have by the nature of their professional roles carried the biggest responsibility for person-centred fundamental care delivery. So, this is what we have learned about getting person-centred fundamental care right: People with COVID and nurses looking after them are challenged by multiple physical barriers that challenge effective communication. There is the PPE, the multiple masks where patients cannot see nurses’ faces; some may not be able to hear what is being said; talking is difficult; physical touch is not appropriate and everyone looks the same so it is difficult for patients even to remember who has been talking to them. Patients with COVID are often isolated in single rooms or in ICU cubicles where they more often than not will be on some sort of oxygen support. These physical constraints reduce their ability to move around freely or attend to their own fundamental care needs such as going to the bathroom or having a shower. All these compound effects exacerbate the patient's experience of physical, mental and emotional isolation and reinforce the separation from their family and other carers. It also increases the workload on nursing and other care staff exponentially. Patients isolated in single rooms may only see one nurse per day at a specific time point where they may or may not have the opportunity to communicate to their nurse in ways that overcome the physical communication barriers and allow them to talk about their fear, loneliness, isolation and existential angst. Conversely, patients with COVID in the EDs, COVID wards or ICU will be exposed to multiple encounters with many different nurses, many of whom will not know the patient or have time to talk with them. Patients may be intubated or at different levels of consciousness and so the interaction with the nursing team may only surface after they have survived a critical incident. We have several high-profile testimonies (notably from the UK Prime Minister Boris Johnson) as to the importance of those relationships and presence of the nurses that helped the patient recover. What we have also experienced is how important it is for the nurse and the whole nursing team to anticipate the patient's holistic needs before they don their PPE and enter the ‘enclosed space’. It is not possible to go ‘in and out’ of the room or in terms of patient needs as we used to do both literally and intellectually, and if you have not undertaken a critical assessment then it is going to be difficult to provide that integrated physical, psychosocial and relational support. You need to be able to ‘stay in the room’ and ‘be present’ for the patient as you may be the only other person they speak to or have contact with that day. And when you have to take care of more patients in different rooms, it is equally challenging to divide your time. You are often called away by another patient while you were having an important conversation and you have to decide how to manage the impact of leaving one patient to tend to another. You need to be able to channel their anxieties and fears and also be alert to their reactions, values and concerns and to be able to do this authentically and multiple times across a shift. This is intense work and can be physically and emotionally draining as well as potentially dangerous for staff who have to manage potential threats from agitated patients in single rooms. Patients with COVID admitted to hospital may have been unwell for several days. They will have been on a journey that will have created significant stress and anxiety. On admission, they will be greeted with more questioning from often faceless strangers who will decant them to various destinations across the hospital. Keeping the continuity of care is vital, not just for nursing teams allocated to an ED, COVID ward or ICU but also for the patient and their family through the recovery process. Discharge from hospital has always been a complex process, and now with COVID, it is even more so. For example, when patients’ family members are not able to visit them because they are COVID-positive themselves, a lot of communication has to be done via telephone. And if you need interpreting and phone services, you increase the risk of miscommunication, especially when you do not have any written information about that care plan. We as health professionals can provide a lot of information, but sometimes we forget about confirming that the patient and carers have understood or agreed with the plan. Some patients are discharged too early from acute hospital wards and end up still sick and anxious at home. Again, it is really important to ensure that the COVID care plans for each patient are retained so that they can enable the next team of carers, either family members at home or aged care workers, to be able to understand how best to deliver safe, person-centred fundamental care. Nursing staff are starting to talk about the relentlessness of COVID, the waves of sick patients, the huge death toll unexperienced by many in their career, the physical, mental and emotional exhaustion, individuals coping with their own private grief and trauma and then having to find the strength and resilience to care for others. If the health system is in crisis itself then the systemic manifestations of chronic overwork and stress will come to the fore. Intolerance, frustration, exhaustion, burnout are symptoms of people in a system not having sufficient respite or time out to recover and rebuild their capacity to care. During the first COVID wave, there was a lot of positive attention for doctors and nurses: everyone saw that they did an extraordinary job; they were acknowledged by being provided with extra food, snacks, cards and even public rounds of applause. In the second wave (which was much longer) the work became ‘normalized’—it was normal that nurses do ‘their job’ in the EDs, on the COVID wards and ICUs, and nurses (and the rest of the team) had to cope with many sicker patients. Now as we anticipate the third wave, the workforce is starting to feel apathetic and disconnected from what ‘normal’ felt like in a pre-COVID world. We will not be able to go back to how it was before COVID, and it might be challenging to think about how we can look into the future—in a positive way—but we must be able to do this, and it requires strong leadership and an ability to learn from our experiences; so we are better prepared for such future scenarios. We do need to remind ourselves that we are in a time-limited crisis that is putting stress on every person and system. So how can we draw on this fact that will give us the belief and confidence to make the right decisions to help us all get through? Again, in nursing, we have heard about ‘missed care’ (Jones & Murry, 2015), the jobs that nurses choose to relegate to a lower priority because they do not have the time or resources. When pressures are high, nurses default to survival mode, and they attend to medication, vital signs and keeping people alive. But when fundamental care is missed continuously—mouths not cleaned, conversations not had, turnings missed, food left uneaten, then the trauma faced by the patients and the nurses will build inexorably. This is also what we know about why nurses leave the profession—they have had enough of justifying why they had to scrimp the delivery of life-saving fundamental care and why no one seemed to be listening to helping them build the workforce that would and could confidently deliver such care, both in times of normality and in times of crisis. This neglect of frontline worker stress would not be tolerated in other high-stress professions such as the army or police. Why (nursing) care continues to be neglected in high-level policy initiatives is incomprehensible (as attested in high-profile failures in care), yet it continues to happen, compromising both patients and nurses. The life-saving work that nurses all around the world have done in delivering person-centred fundamental care to patients with COVID is as special, as important and as complex as the armies of scientists who have been working tirelessly to produce vaccines. Of note has been the rapid and welcomed additional investment into vaccine research; yet we have not heard of the investment plans governments have generated to make sure their frontline staff are supported to do their work. Indeed, we have heard the contrary; shortages of PPE; staff having to buy their own equipment; insufficient numbers of staff to care for patients and lack of support to manage the stress. We have also identified an indifference creeping into systems around just how staff should be coping with the ‘new norm’. The unfortunate reality is that our health systems have never really adequately addressed person-centred fundamental care delivery and so when we are faced with a pandemic that is reliant on us being able to manage this, we see the cracks in the system. Rather than being self-evident and straightforward, fundamental care work is highly complex as it requires emotional and intellectual capability as well as clinical skills and knowledge. Having structures in place that help nurses to process the traumas they see on a daily basis should be a norm in most healthcare settings and particularly in response to COVID. What can we build on for the future? We reckon there are five very practical things we can do: This editorial is dedicated to all the nurses around the world who have paid the ultimate price in their service to patients. We acknowledge their commitment to person-centred fundamental care. Our task now is to make sure that what we have all learned from COVID and continue to learn will ensure that our systems embrace more humane and safe ways to care. We also commit to improving the way nursing staff are cared for themselves. None.

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