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‘Building the plane while we were flying it’. Nursing on the COVID frontline

Introduction by Croakey: Learning from nurses’ experience throughout the Australia’s COVID-19 pandemic can help equip our health system for future pandemics and other health challenges, as the recent Australian College of Nursing National Nursing Forum demonstrated.

In the #LongRead below, Jennifer Doggett reports from multiple sessions at the forum on how COVID-19 and its resulting lockdowns have had major and diverse impacts on nursing across Australia, causing stress, disruption and exhaustion while also prompting innovation, flexibility, and generosity.

Bookmark all the #NNF2021 coverage, for the Croakey Conference News Service.


Jennifer Doggett writes

As Melbourne nurse Karrie Long put it, “one pandemic year equalled three normal years” for a hospital working at the frontline of the COVID pandemic in Australia.

Long was one of many nurse leaders who presented at the recent National Nursing Forum on experiences on the nursing frontline in the pandemic, ranging from a metropolitan hospital at the “epicentre” of the pandemic in Australia to the ripples across health care in Arnhem Land.

The presentations conveyed a general picture of stress, uncertainty, changing advice and unsafe practices as the hospital and broader health system struggled to meet the demands posed by a new and potentially catastrophic health threat.

However, they also described positive examples of nursing and health system leadership and resilience and creativity in responding to a unique and constantly changing work environment.

It’s clear from #NFF2021 that the COVID-19 pandemic has provided the health sector with far more than 18 months of learnings – critical work as Shadow Minister for Health Mark Butler outlined, warning delegates that “we still have a long way to go with this pandemic”.

Butler reiterated the request he has made repeatedly to the Prime Minister to release the hospital modelling given to National Cabinet to guide the re-entry process.

He also called for greater support for public hospitals which he said are “already under very serious pressure” to prepare them for an increase in COVID cases once the lockdowns end and borders re-open.

Butler stressed the need for a collaborative approach across jurisdictions to combat the next stage of the pandemic and called on the Commonwealth to avoid “picking fights” with the states and territories.

The keynote and concurrent sessions at NNF explored diverse experiences in nursing throughout COVID-19 which varied according to location, role and stage of the pandemic.

“We all have our own COVID story and not everyone’s is the same,” noted Karrie Long.

In the opening session of the conference, ACN CEO Kylie Ward highlighted the crucial role of nurses in all areas of the health system during COVID-19, stating that “without nurses, Australian would have had no pandemic response.”

However, ACT Chief Nurse and Midwifery Officer, Anthony Dombkins also made the point that throughout the pandemic nurses have continued to work in non-COVID areas of healthcare. “COVID does not define nursing,” he said.

Leading with kindness

The Royal Melbourne Hospital (RMH), which in 2020 was caring for 40 percent of Australia’s COVID cases, was the focus of key presentations at the conference.

In one, Associate Professor Denise Heinjus, RMH’s Executive Director Nursing Services and Residential Aged Care, said the hospital’s core values of “leading with kindness, people first and excellence together” helped set the tone for their early response.

She also noted that RMH made a decision to avoid using “warlike” language when discussing COVID.

A major challenge in the early days of the outbreak was a shortage of PPE but Heinjus said that staff were reassured that no-one would be asked to provide care without adequate protection.

The responsibility RMH had for outreach into the community included making initial assessments of high risk aged care facilities and in some cases taking over their management to ensure residents were protected.

Nurses asked to provide care in these facilities were shocked by the conditions they experienced and described them as the most stressful shifts in their career, she reported.

Balancing the need to manage infection control with supporting the residents in Melbourne’s public housing towers, who experienced a hard lockdown without notice and under police guard, was also extremely difficult, Heinjus acknowledged.

The hardship being experienced by the residents and the chaotic situation made it difficult for the RMH nurses to provide quality care and screening services.

Another distressing experience for nurses in the early days of the pandemic was the creation of a temporary mortuary at RMH for patients who died.

Heinjus ended her presentation by emphasising the need for ongoing support for nurses and other hospital workers. She said:

Staff are tired and many are grieving. Families are stressed and burnt out.

We need to support our workforce for the next waves of the pandemic.”

Code Yellow: caring for staff

One way in which support for staff, from clinicians to cleaners, at the RMH had to be stepped up was discussed in a separate presentation by Karrie Long, Director of the Nursing Research Hub.

She described how the rising numbers of COVID patients at RMH during Melbourne’s 2020 second wave led to increases in the number of staff either infected or needing to be quarantined due to contact with someone who was positive.

As many RMH staff lived and worked together, when one staff member tested positive, many others would need to be quarantined, placing additional pressure on the hospital’s already stressed workforce.

To support staff in quarantine or home isolation RMH set up a nurse-led taskforce which over a four month period in 2020 made 4,000 phone calls to around 700 staff infected and quarantining at home.

The calls aimed to provide emotional and practical support, identifying any specific needs they had for food or other supplies, and also provide clinical assessments and advice for those with COVID symptoms.

More than 14 staff experienced more than one instance of 14 day quarantine, and one person spent 41 days in quarantine, Long said, describing the importance of a multidisciplinary team, including a social worker and mental health nurse.

Long described the project as an example of “value-based leadership” adding that “investing in staff well-being is vital to protect our greatest workforce.”

“This was one of the greatest responsibilities I’ve ever had, probably one of the proudest moments in my career,” she said.

Some of the challenges she identified in implementing the taskforce were a lack of clarity around governance and scope of the taskforce.

“These were not our patients, these were our colleagues,” she said, noting that the unprecedented situation meant the team was “building the plane while we were flying it”.

She also reported some data and technology issues as most of the nurses working in the taskforce were not used to working from home and did not have the technological infrastructure required already in place.

Preparing for COVID patients

While RMH was dealing with the first wave of infections, another major public hospital in Melbourne was preparing for a likely influx of patients as the pandemic progressed.

Ashley Wheeler, General Manager of Surgical Services, described how St Vincent’s took advantage of the empty wards, created as the hospital moved patients to private facilities in anticipation of incoming COVID patients.

These wards provided a space to establish a simulation ward to develop test and modify COVID models of care prior to receiving patients, helping the hospital prepare for the different demands involved in treating COVID patients, such as the use of PPE, handover arrangements, entry and exit protocols and the safe management of Code Blues (medical emergency) and Code Reds (fire or smoke).

It helped to develop consistent processes across all areas treating COVID patients and was used to train over 750 staff.

The benefits provided by the simulation ward included greater consistency across all wards with COVID patients and increased staff confidence, particularly important for surgical nurses who were being moved to medical wards and needed upskilling in infection control processes.

Wheeler noted that this training had set the hospital up well to deal with the Delta strain outbreak this year.

In a separate presentation, Wheeler discussed a new nurse-led surgical framework and model of care implemented at St Vincent’s to manage the safety and monitoring of surgical patients whose procedures were postponed during the height of pandemic.

This included the development of multi-disciplinary pre-admission telehealth services, transforming the traditional face-to-face model that had remained unchallenged for decades.

Some of the changes made through this model, such as the implementation of more flexible work arrangements, have now been implemented permanently, resulting in reduced sick leave and improved staff satisfaction.

Impact on nurses, patients and families

NNF heard that nurses had been adversely impacted by the demands placed on them during the pandemic but had worked hard to shield their patients from any potential effects on quality of care.

Dr Suzanne Sheppard-Law undertook a cross-sectional survey of nurses working in health-care settings and found that 80 percent of respondents reported experiencing generalised anxiety as the pandemic progressed, a statistically significant increase from their baseline scores.

One recommendation coming out of this study was to support nurses to undertake mindfulness practices and other self-care strategies to minimise stress.

The specific impact of necessary but harsh infection control measures was also discussed by Dr Robin Digby from Deakin University, who held focus groups with staff working on the frontline in an acute hospital to discuss the effects of isolation on patients, families and staff.

The staff participating in the groups acknowledged that isolating patients, restricting visitors and limiting staff movements within the hospital were good pandemic management, but they felt that this came at considerable cost to patients, families and staff.

All groups highlighted the importance of good communication as important to reducing the impact of isolation, leading to Digby’s recommendation that hospitals develop the infrastructure needed to support alternative means of communication to cope with future pandemics.

Heading into the storm

An “outsiders” perspective was provided by Hannah Rohrlarch and Annabel Thomas, South Australian nurses who responded to a request from the Victorian Government for help in managing the 2020 outbreak in residential aged care facilities (RACFs).

They described walking into a situation of chaos on their arrival in the Melbourne RACFs, including inconsistent and disorganised PPE and infection control processes.

Adding to the chaos were the large numbers of agency nurses being used in the RACFs as many of the permanent nurses were either themselves infected with COVID or in quarantine.

Rohrlarch and Thomas emphasised that this was not the fault of the nurses at the RACFs who were working under extreme conditions with inadequate guidance and support.

They described their role as supporting existing RACF leadership to implement strategies to protect residents from the risk of infection, including separating the facilities into red and green zones to keep COVID positive patients isolated.

They also outlined the comprehensive measures undertaken to prevent the nurses from spreading infection to each other or the broader community while in Melbourne. That included separating the nurses working at different facilities, providing them with hotel accommodation on separate floors, travelling in private cars to and from the RACFs and implementing special arrangements for laundry and meals.

Despite the many challenges they experienced, Rohrlarch and Thomas reported that the relief and gratitude they received from staff, residents and families at the RACFs meant that they would both put their hands up to do this again.

Regional nursing experiences

While there were some issues in common with urban centres, regional healthcare services reported additional unique challenges as the pandemic unfolded, given their geographical isolation from city centres, limited access to equipment and a smaller pool of staff with the skills and experience to care for COVID patients.

Associate Professor Jennifer Weller-Newton, from the Department of Rural Health at the University of Melbourne, described the use of reflective practices in helping nurses to explore their role as frontline healthcare workers in a regional healthcare service and to support their well-being during the challenging times.

Her research involved encouraging healthcare workers to provide her with a monthly reflection of their lived experience represented as an anecdote, story, poem, collage, image, or painting. An analysis of these reflections identified some common themes, including relentless fatigue and workforce pressures, coupled with a sense of solidarity and pride.

Weller-Newton found that this reflective practice offered participants a moment of stillness and space in an otherwise chaotic and stressful environment and she recommended that further innovative avenues be considered to enable health care workers to experience ongoing reflectivity in their work.

Another story from regional Australia came from emerging nurse leader, Emma Bugden, who described the challenges of working in remote Arnhem Land in the early stages of the pandemic, and how it exacerbated existing challenges for nurses in her community, such as significant staff shortages.

The border closures and movement restrictions meant that agency nurses were no longer available which meant that some nurses were required to work for 12 months straight without any recreational leave.

Adding to the workforce pressures was frequently changing and sometimes unsafe advice from health authorities, particularly around the use of PPE, she said.

Bugden outlined how in the early days of the pandemic nurses were told not to use PPE – even when it would be unsafe for them to treat patients without it – because it was in such short supply. They were also discouraged from wearing PPE when treating people with flu-like symptoms because of concerns among health authorities that this might lead to panic in the community.

Staff were also warned that there could be backlash from the community if any COVID cases were detected and told they would have to be evacuated quickly, which she said was a very stressful situation for the nurses and their families.

There were also additional restrictions placed on their movements due to the biosecurity laws which meant that nurses living and working in remote communities were often unable to leave the boundaries of their community for months on end.

Many communities also experienced widespread food shortages as the number of barges delivering food halved and online food shopping was restricted.

Despite these challenges, Budgen reported that nurses found innovative ways to cope with the stressful environment including bonding together for support and mentoring.

The Colac experience

Colac is about as far away from Arnhem Land as is possible on mainland Australia but while the challenges in the regional Victorian town were different from those at the Top End, the situation was equally demanding for the nursing workforce.

In 2020 Colac experienced the biggest regional outbreak thus far in Australia with a total of 145 people infected ranging in age from 8 weeks to 92 years.

Colac Area Health CEO and registered nurse Fiona Brew described how Colac was on its own in responding to this outbreak as the authorities were focused on the bigger second wave in Melbourne.

She outlined the steps they took including setting up an incident management centre to investigate the clusters appearing in local abattoirs, childcare centres and schools and in the Bulla ice-cream factory.

They investigated the living conditions of the abattoir workers and discovered that some of them were sharing accommodation with up to 12 other people, including shift workers who would sleep in the same beds.

Introducing hotel quarantine to isolate people who were positive, or in close contact with people who were positive, involved looking at a range of issues, such as ventilation and infection control.

Brew reported that some of the challenges for health services included meeting the communication needs of Colac’s large cultural and linguistically diverse population.

Many of the abattoir and factory workers spoke languages other than English and needed interpreters to understand the information being provided by health professionals and local authorities. However for some, such as Farsi, they had to find local people to act as interpreters. They also needed interpreter services to produce infographics and written material in other languages, including Arabic, Farsi and Mandarin.

There were also issues with the food was provided to residents in hotel quarantine or home isolation which was often not culturally appropriate and did not include some important items like pet food.

Brew told the NNF that key lessons from Colac’s experience included the importance of trust in local health services and of businesses keeping employee contact data up-to-date, the need for same day testing, the role of workplace-based testing and the need to involve community leaders in the response.

Learning from experience

The experiences of nurses throughout the pandemic, and the research that is being undertaken on these experiences, are a rich and diverse resource which has the potential to improve the delivery of health care across geographical areas, health sectors and communities.

As Australia moves slowly towards a “living with COVID” or even “post-COVID” environment, these lessons should be used to strengthen the capacity of our health system to combat future pandemics and to address other longer-term health challenges facing the Australian community.

Disclaimer: Jennifer Doggett provides consultancy services to the Australian College of Nursing.


See Croakey’s archive of stories about nurses and nursing.

See also our coverage of the 2019 NNF.

 

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