Observations

One Year Later: Lessons from the Front Lines of the Pandemic

Thoughts on leadership, stepping up when needed, and communicating with families

Editors’ note: Tiffany’s column “Nursing on the Front Lines of COVID-19” was published in March 2020. It detailed her experience as an ICU nurse in Washington State, treating the first coronavirus patients in the country. This is her follow-up to that account.

 

“525,600 minutes. How do we measure, measure a year?” — “Seasons of Love,” RENT

How do we measure 2020 — the Year of the Nurse, and the first year of the COVID-19 pandemic? It would be easy to add up the painful memories, the damage and the myriad ways in which we’ve suffered. That’s valid; we need to honor our suffering.

However, as nurses, it’s just as important for us to measure the ways we’ve grown from our mistakes and hardships. Here are a few of the lessons I’ve learned after 525,600 minutes on the front lines of the pandemic.

Lean on Experience

Last March, reality barreled through our medical ICU like a runaway train as we admitted our first COVID-19 patient. The clinical educator distributed PPE and detailed the protocols for its use, droning, “Sanitize, first pair of gloves, gown, second pair of gloves.”

Anxiety surged in my solar plexus as I stretched the blue surgical glove over my fingers, a thin barrier against an unexpected, poorly understood disease. My fear must have shown, because my colleague, a soft-spoken nurse in his 50s, placed his hand on my shoulder and whispered, “I’ve been through scares like this. Trust me, we’re going to be OK.”

He reminded me that just a few decades ago, the world faced another deadly viral crisis: AIDS. Feeling like a beginner all over again, I turned to the calm presence and clinical competence of the seasoned healthcare veterans around me, leaning on their wisdom.

We sometimes overlook senior staff when technologically savvy, adrenaline-driven fresh recruits enter the scene, but our elders’ experience and resilience are irreplaceable. These veterans have adapted to industry transformation and weathered many crises. They’ve seen it all and survived.

Embrace the Novice

As the COVID-19 patient census surged around the nation, staff recruitment was frantic. We called for all hands on deck, and our department was soon brimming with new hires, travelers, and even new grads. With precious little time to get to know our colleagues, we had to trust each other’s qualifications.

Travelers may need a little orientation to a new ward, but they easily adapt and bring a fresh perspective. Novices might be at a chronological disadvantage, but are full of potential, reinvigorating an exhausted crew.

The past year has been a pointed reminder that the old-school mentality claiming that nurses “eat their young” doesn’t serve us and never has. Those who can’t or won’t foster an open-minded reception and help newcomers succeed will only create unnecessary struggle for everyone.

“Not My Job” Is Not an Option

Nurses are resourceful agents of change. However, we can also be … well … a bit territorial and prideful about our jobs.

Hiring Now

I was stunned one shift when a mop and bucket of bleach were placed in my hands. To avoid exposure, housekeepers weren’t allowed behind the barricade separating COVID-19 patients from the general population, so nurses were suddenly placed on cleaning duty.

“It’s not my job” is a cringe-worthy phrase, but I was tempted to say it anyway. I bit my tongue; an overflowing census, staffing shortage and limited PPE supplies made those words categorically off-limits.

We can argue about the unfairness of nurses having to stand in for phlebotomists, spiritual care, social workers or housekeepers, but sometimes, we just have to do whatever is necessary. The past year demanded maximum cooperation. It’s been a time to reflect on and appreciate the critical role every single discipline plays in patient care.

Communicate with Families

Of all the heartache I witnessed in 2020, the pain created by the visitor restrictions remains some of the hardest to reconcile. I’ll never forget telling a patient’s adolescent daughter, “this is your last in-person visit” — the next day, even family members would be banned indefinitely.

How would I cope if I waited helplessly at home, desperate for word about my parent or child? It’s an unbearable thought, yet millions lived it (and many are still living it).

It’s imperative to keep family members apprised of a patient’s condition, but the restrictions have made it harder than ever to maintain those crucial connections. Communicating by phone isn’t always a practical or feasible alternative. Extreme stress, variable health literacy and language barriers can make it even more difficult.

Those challenges must be mitigated. Families are essential allies for patient safety and quality of care. Also, visitors are a source of comfort and distraction for patients. They are advocates, encouragers and entertainers.

Here are some simple, effective strategies for communicating with families:
  • One spokesman. Negotiate for there to be one person to represent the family. Document their contact information. This will avoid the problem of staff making multiple calls to convey the same information to different parties.
  • Establish a schedule. Alternate calls between nurse and physician if necessary. Document completed calls.
  • Involve others. Charge nurses are excellent substitutes when primary staff are unavailable. Communications can be entrusted to social workers and spiritual care when medical updates aren’t warranted. Often, a supportive check-in is what families most need.
  • Use technology. Video chats are a more personal option for updates from staff and allow more direct family contact with the patient.
  • Get creative. Families want to stay connected. Even as one of my patients was in a medical coma, she received a daily phone call from her daughter. I tucked the phone next to my patient’s ear while her daughter sang to her in their native language.

Innovate, But Follow Rules

Treating a new disease calls for investigation and fresh ideas. It’s exciting to test new research and evaluate results. It’s especially rewarding to recognize trends, implement novel strategies and see patients recover.

Nursing Education

However, it’s important not to get ahead of ourselves. Untested solutions present unexpected risks, and innovation is dangerous without proper safeguards. We follow evidence-based practice, but when new modalities are implemented without sufficient evidence, the lines between ingenuity and simply going rogue are blurred.

PRONE POSITIONING

Take for example, prone positioning. First demonstrated in the ‘70s as a successful ARDS [acute respiratory distress syndrome] therapy, prone positioning has been applied to COVID-19 patients who required ventilator support and met certain criteria.

When rumors hit our hospital that prone positioning was being tried for non-ventilated patients, some nurses were tempted to go to every room and turn patients onto their stomachs. But doing so raised important questions about whether that action would be appropriate. How was the practice studied? Did the benefits outweigh the risks? Were there legal implications to consider?

PROCEED WITH C.A.R.E.

If an outcome is less than beneficent, every action will be scrutinized. Even in a crisis, we must be ethical, work within our scope of practice and protect our licenses. It’s possible to navigate unknown territory if you follow the acronym known as CARE:

  • Consult with supervisors and/or medical directors
  • Adhere to your scope of practice
  • Review/research applicable policy and procedures
  • Employ the nursing process.

Leaders Have a Crucial Role

As the pandemic continues its rampage across the globe, the tired trope of the nurse hero is intensifying. The title “hero” comes with a heavy price: On the front lines, we’ve risked both exposure to the virus and secondary trauma. We’ve suffered isolation, anxiety and depression. When carrying such burdens for our communities, gathering the strength to ask for help can be a staggering task.

Fortunately, solutions are easier than we might think. Don’t let social distancing be an excuse to disconnect — staff support truly takes a village.

Here are ways that nursing leaders can help staff bear the load during the pandemic:
  • Leadership must communicate authentically and regularly, in writing and verbally. Use a central command center approach to ensure the messages are accurate and consistent, reaching all employees. • Rotate bedside staff between low- and high-acuity patients. Alternate assignments to prevent burnout, staff turnover and errors.
  • Facilitate formal debriefs as opportunities for professional growth and personal reconciliation. These are vital when patient outcomes are tragic or unexpected.
  • Use informal debriefs as a safe space to reflect and grieve collectively. Consider establishing post-shift huddles, weekly support groups and a designated virtual space.
  • code lavender. A breakthrough concept for emergency staff support is “Code Lavender”: When an employee experiences extreme stress, trauma or challenging events, a skilled team responds with instant support and community referrals.
  • Regularly scheduled, one-on-one check-ins with leadership are powerful. Address concerns, ensure access to employee health services and plan for follow-up.
  • Celebrate successes. As much as we need a place to share grief and regrets, we need to share our wins. Get creative and celebrate patient triumphs, such as meeting milestones or being discharged home. Honor employees by showcasing personal and professional accomplishments.

The past year has left us battle-scarred, exhausted and pushed to our limits. It also caused us to reflect on the cornerstones of nursing: collaboration, communication, critical thinking and empathy. The devastation we’ve endured shouldn’t diminish these qualities. Even amidst the chaos of COVID-19, safe and successful patient care is possible — in fact, it’s happening every day.

The lessons learned from the past year of the pandemic will enable us to move confidently into the future.


Tiffany Swedeen, RN, BSN, CPC/CPRC, is a clinical nursing instructor and founder of Recover and Rise coaching. www.recoverandrise.com


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