Voices from the field!

Nursing leaders speak from the first battlefront to open, on the war against COVID-19 at Kauvery Hospital, Tennur, Trichy

Abstract

Background

The COVID-19 pandemic affected all countries in the world. The outbreak was first identified in December 2019 in Wuhan, China. The countries around the world cautioned the public to take responsible measures to prevent and control infections, and seek care when sick. The public healthcare strategies included handwashing, wearing face masks, physical distancing, avoiding mass gatherings, assemblies in ill-ventilated premises, and testing-tracing-isolating. Nurses have been at the forefront of promoting health, advocating for patients, and advancing the science of care. This pandemic exerted extraordinary pressures on nurses globally, and placed them at great risk, as they were at the front line of care.

Aims

This study aimed to explore the experiences and challenges encountered by nursing supervisors and nursing-in-charges who worked with suspected out-patients and/or hospitalized patients with COVID-19 at Kauvery hospital, Tennur, Trichy, Tamilnadu, during the pandemic years of 2020-2021.

Participants

The participants were nursing supervisors and nursing in-charges who were responsible for taking care of COVID-19 patients in hospital. Prior to data collection, participants were given a full explanation of the study objectives and procedures, and informed of their right to agree refuse to participate or withdraw from the study at any time. All data were kept anonymous, to be used for research purposes only, and kept strictly confidential in a locked cabinet or via encryption, with access given only to the research team.

Data Collection

Experienced nursing in-charges and supervisors were invited to share their experiences through a written document and voice response while continuing to care for people with COVID-19 and managing staff nurses and health care workers.

They were specifically requested to write about their challenges encountered and strategies adopted to address them. They were also invited to express their views about the preparation of nursing staff towards meeting these challenges over an uncertain duration of time, which could be years. They were requested to comment on supporting and training new nurses, and about the allocation of duties that are required to be undertaken to efficiently and successfully address future pandemics.

Background

The increased infection rate during the pandemic period resulted in a high mortality rate and, globally, many health professionals succumbed to the virus. As reported in the media, both locally and internationally, the death of health care workers had dire consequences on the delivery of health care services to each nation’s population.

It is well known that nurses are the backbone of the health care system, and the nursing workforce is led by nurse managers whose responsibility is to ensure the delivery of nursing care and perform other managerial tasks for the smooth running of the health care system.

The COVID-19 outbreak came as a shock to all health care sectors throughout the world and no one was prepared for such a deadly virus. Since it was still a novel disease, many studies began to emerge on its prevalence, evolution, and management. As the prospects for vaccination emerged, many trials have been conducted on health care workers too. However, there are limited studies that have been conducted on the experiences of nursing supervisors and nursing in-charges during COVID-19. So, this study aimed to fill this gap by exploring their experiences during COVID-19 in the setting of the busy COVID wards at hospital.

Studies on experiences of nursing supervisors and nursing in-charges during the era of COVID-19 are valuable information that shall guide the management of the pandemic situation, in evolving strategies to support nurses, to ensure the smooth running of hospitals, and in rendering quality patient care. Nursing supervisors and nursing in-charges are responsible for taking care of COVID-19 patients. At the same time, they must also manage health care facilities, enhance productivity, efficiency, sustainability, and minimize risks. The psycho-social impact of COVID19 cannot be underestimated and nursing supervisors and in-charges have been under great pressure, and stress, making them vulnerable to mental health issues.

Nursing supervisors and nursing in-charges courageously and resolutely met the challenge when COVID-19 heaped on them a load of administrative responsibilities in addition to patient care.

Voices from the field

Nursing Superintendent Ms. Mahalakshmi says

As we all know COVID-19 originated in Wuhan City, Hubei Province, China. The disease was reported to the World Health Organization on December 31, 2019. On March 11, 2020, the World Health Organization declared COVID-19 as a global pandemic. We had a group discussion with the Managing Director, Medical Administrator, Facility Director, Nursing, and Operation Heads’ to manage the COVID-19 pandemic at Hospital.

We had modified the infrastructure as per the Government stipulations and created 25 beds to accommodate critical and non-critical COVID-19 patients. We discussed with the Medical Administrator, Facility Director, Nursing Head, Intensivist, Physician, and Microbiologist about infrastructural changes on the fifth and sixth floor of A block for accommodating COVID-19 critical care patients.

Trichy Joint Director of Health Services (JDHS) and the team came for inspection and approved us as an authorized COVID-19 center. We conducted multiple training sessions on donning and doffing of Personal Protective Equipment (PPE) at all levels of health care workers. We arranged counseling sessions to motivate and guide the health care workers to mitigate anxiety; this was organized by Managing Director, Medical Administrator, Microbiologist, and Nursing Heads. We developed Outpatient Department (OPD), admission, discharge protocols, O2 management, and COVID-19 management protocols (mild, moderate, and severe) including investigation, and medications, as per MOHFW/ICMR Guidelines.

Initially, we received suspected Severe Acute Respiratory Infections (SARI) and Influenza-like infections (ILI) patients only in COVID-19 ward. The first positive case was admitted during the month of June’20. We created packages for pharmacy, investigation, billing, etc which made these processes efficient and economical to patients. We designed COVID-19 case sheet for documentation with proper assessment, reassessment, and Modified Early Warning Score (MEWS) chart. As the days went by, when the number of COVID cases began to increase, we extended second to fourth and sixth floors as COVID-19 wards. We started COVID-19 care center (CCC) for stable patients in Red Fox Hotel. The maximum number of patients admitted at Red Fox was 70 per day and was managed successfully with the help of operations and marketing teams.

Challenges Faced

During the first wave, we faced shortages of PPE, face shields, and medication shortages, and our staff innovatively created face shields by themselves!

During the second wave we encountered shortages of oxygen (O2) supply and O2devices, so we assigned O2 nurses individually to monitor the usage of O2 throughout the wards.

We took steps to conserve O2 and ensure efficient utilization:

1. Reduced wastage of O2
2. Ensured optimal utilization of portable O2 cylinders
3. O2 use was monitored by the O2 nurse.
4. Emergency O2 cylinders were positioned wherever it was appropriate in the critical care area.
5. Reuse of O2 devices after proper sterilization and disinfection.
6. Unused O2 flow meter removed from the O2 port to minimize the O2 leakage.
7. The operation team went directly to the O2 vendor site and ensured an uninterrupted O2 supply.
8. We used an O2 mask, NRBM, and NIV instead of nasal prongs and a High Flow O2 meter to reduce the O2 leakage.

We faced problems with dispensing medications to the right patient at the right time but that was rectified by runner boys.

We supplied the food for the patients. Initially, patients complained that food was coming late and also complained that it was very cold but these issues were overcome by supplying the food at the proper time and proper manner by catering staff and patients felt happy and satisfied.

COVID-19 pandemic has challenged and continues to challenge us as humans and as health care providers. It challenges both the health care system and our society. This pandemic has overpowered innumerable elements of society- supply chains, vulnerable populations, families, educational systems, holidays, and personal milestones-but it had the opposite effect on nursing. It enabled and empowered nurses to serve society boldly and effectively, infusing them with pride and satisfaction. It persuaded the public to take pause, recognize the potential, and respect the voice, actions, and service of an otherwise quiet and anonymous profession.

Thank you, everyone (Nursing department, Operation team, Marketing team, other Health care workers) for the sacrifices you-all made, every day and especially during this pandemic. Your dedication, commitment, and courage deserve our deepest gratitude and admiration. During these tough and unprecedented times, you always put patients first.

The voices of our supervisors and in-charges!

“Nursing supervisors and in-charges found that COVID-19 brought a lot of administrative duties in addition to patient care”

Nursing supervisor Sr. Arputhamary says

Initially, I was very panicky about this spread of the COVID virus, increasing death rates, quarantine etc. We had lots of confusion in our minds about this COVID-19; every day new protocols and criteria for managing the patients were posted, based on emerging evidence. We did not know “what to do? and “what not to do” in COVID. What is the protocol for declaration of death? How to wear PPI? How to arrange equipment? There was a shortage of PPE, and there was staff sickness!

“I could not make an alternative allocation because there was a huge shortage of staff, everywhere. I could not ask other wards to let me use their staff temporarily, or get a substitute from other wards”. We were not only engaged in saving people from COVID-19, but also had to attend to equally pressing non-COVID problems, like treating people traumatized from accidents, and ill from other life-threatening illnesses. But our management supported us in many ways, like frequent refreshments, arranging the equipment, supplying PPE, food delivery for all nurses, hostel accommodation, transportation, and monetary benefits. And laterally, we gained lots of confidence, and we were mentally strong to fight against the COVID-19 pandemic.

Nursing supervisor Sr. Leema Rebakkal Rosy says

Working as a nurse during this terrible pandemic has been a humbling experience for all of us. It was total immersion.

I was working in the ICU as a nursing supervisor when the pandemic began.

A few months later, I was relocated to the COVID unit. During the pandemic, entire floors had been converted into COVID-19 inpatient units. It was an extraordinary challenge to work with COVID-19 patients. First, I went through extreme anxiety, reluctance to be exposed to the virus, and carrying it home to my family. In addition, the work was incredible in its complexity. Nurses jumped to take on other duties on the COVID floor to avoid the compulsion to use personal protective equipment. We didn’t know what to expect and were understandably afraid, however, in this pandemic, time helped us to bring our team together. Every staff member in our department banded together to fight against this COVID-19 pandemic. We ensured each of us wore the proper PPE, despite the frequent changes of the protocol. We listened to one another’s fears and raised each other’s spirits every day. We worked equally hard for every COVID-19 patient. They were real tears that came to our eyes and it was a real fear that we saw in their eyes. We provided compassionate care to every patient coming to us for COVID care. We made video and audio calls to their loved ones, to keep them connected, or to inform them of the status of the patient. Through all this, when the patients deteriorated, it was heartbreaking to discuss with their family members. It was an emotional ride on a roller-coaster. When the patient got into low O2 levels, they could suddenly become critically ill. Of course, it’s never easy to witness my patients’ suffering, but I never gave up on any of them. I held out hope and prayed that each would survive. I cheered each patient that I discharged home, and seeing them reunite with a family member put a smile on my face. Most of all, I got appreciation and support from my family. They encouraged me to keep going. When I wore PPE, I was unable to eat or drink water for 8 to 12 h on duty. Yet I served with devotion. I got to meet my family members and children only once a week because they lived far away from the hospital. My husband got to work from home; he struggled to take care of his office work as well as our children and family.

This pandemic helped me to grow as an efficient leader to supervise the COVID patient as well as staff. I have given continuous reports to MD, Med Admin, FD, Nursing Superintendent, to other doctors, and in-charge of other units. I felt very happy that everyone in my unit knows me, where am I, and how am I. I am really proud to be a nurse in that situation. Although it may take years to process all these events, I know that every day I show up, I shall strive to bring hope, peace, comfort, and joy to every single person I encounter. It has been my greatest honor to have been a registered nurse in a time like this.

Nursing supervisor Sr. Kalaiarasi says:

I have been working here over the past 10 years and guiding my departments successfully. When everything was normal, suddenly COVID 19 pandemic changed everything!

One day I received a call from Nursing Superintendent advising me to come for COVID duty for 7 days, with all the required things to stay at a hostel. This was at a time when the whole world was panicking about COVID-19 pandemic. Our family members were refusing to let us go for COVID duty. But I was determined to take courage, meet the call of duty, manage the COVID patients to the best of my abilities in spite of my health issues like post thyroidectomy status and allergic bronchitis and win the war on the coronavirus.

I have been proud to be a nurse and serve in this pandemic situation for the past two years. I have taken up the role of making a duty roster for nurses apart from the supervisor role. Our routine shift duty used to be 7 h a day or 12 h at night. But it was very difficult to do duty with PPE for more than 6 h. So, I had a challenge in duty rota preparation with the shortage of manpower, and hesitation of nurses to work in COVID ward. A major concern was attending phone calls from the patient’s relatives who were very anxious about the patient’s health condition. I was also worried about my family and my two young children. I felt very happy and satisfied by providing my service to the needy during this pandemic. I have the whole heartedly played my role and sincerely thank Kauvery Hospital to have provided me with this opportunity.

Nursing In-charge Sr. Anandhi says

During the pandemic, we were panicking and discussed the negative emotions, frustration, anxiety, and stress. Each expressed their anxiety in confronting the unknown, and from the uncertainty and insecurity stemming from both the constantly changing protocols related to patient care and the continual changes around the proper use and allocation of PPE. We had greater concern about the COVID-19 patients. It was difficult for us to be wearing PPE and arrange all the patient-related instruments and equipment correctly; we had a lot of stress in that situation. Severe shortages of testing supplies, extended waiting times for results, shortage of PPE, and difficulty in allocating adequate staff were other factors that greatly stressed us. Fortunately, we have improved our communication skills. We have acquired more confidence about managing COVID-19. We learned to express the heavy emotional toll exacted on us, seeing patients dying without their families present, and how we as nurses did everything in our power to fill the gap and be the family.

We had no time to spend with our family, but our management supported and guided us to manage ourselves during this pandemic situation.

Nursing In-charge Sr. Emalda Mary

The nurses were struggling with some large losses – wedding plans put on hold or changed, graduation celebrations postponed or cancelled, family time interrupted, vacations cancelled, personal appointments put off. Initially, I didn’t want to work on COVID duty; even my family members were adamant that I should not go to work. When COVID cases were at the peak all wards had changed to COVID wards. I was so scared to handle COVID patients because I was worried that if I get infected, my two years old baby would also get infected. At the peak time of COVID I faced many difficulties while wearing personal protective equipment (PPE). I was unable to take adequate water, or take food properly, not even able to go to the restroom. But our management supported us in many ways; I felt I am in a comfort zone, with guidance from our hospital. I, in turn, supported and guided my ward staff. I am so proud to be a nurse.

Nursing In-charge Sr. Sheela J says

There was a sense of fear and restlessness when I was first deputed to the COVID ward. Hearing bad news daily, from around the world, increased my fear. Everything was a new experience after that. PPEs, phone calls, patients, ventilator alarms, monitor beeps, alcohol smell, desperate attendants – all became my routine. Long working hours coupled with family commitments made me hit the ground running, all the time, but my body adjusted to the grind after a week. Convincing family members was a big deal during the initial pandemic days.

On a personal note, I had to postpone our plan for planning a child, citing the pandemic as a reason!

I felt down initially when my own co-workers started avoiding me in fear of catching COVID from me. My house owner would not allow me to enter his house to pay rent, and ask me to keep it outside in a spot. My neighbors’ children were not allowed to speak to me. More than emotions, it was a feeling of rejection from my friends, family, and work. A little more into the COVID pandemic, I started to experience a scheduled life and work, 8 am to 8 pm work for 3 days, hospital transportation, 3 days leave, and repeat. Seeing empty roads, closed shops, and prayerless temples were difficult.

With each day passing, the non-availability of beds and handling that situation became difficult. Sometimes we felt helpless and guilty when asking a patient to go to GH or some other hospital, not being able to admit it here. Managing bed shortages and increasing O2 requirements at a time of O2 shortage posed enormous strain. We could see both the rich and the poor, waiting long hours to get a bed. I felt gutted when I could not arrange a bed for my family member. I tried to take care of all my patients the same way. My thinking was focused on one objective, which was to make the patient recover and be discharged safely home, as these patients were parents, grandparents, sons, daughters, neighbours, friends fighting this COVID alone in an isolated room.

On a positive note, this pandemic helped me to grow as a leader, to supervise COVID patients, give continuous reports to MD, MA, FD, NS & to other doctors and in-charges of other units. That it made me a familiar figure in the unit was a special feeling. I was glad to have a team of co-workers who laughed with us at a time of stress. My phone was always busy and I could feel that I was glued to it. Incentives were given to us nurses working in COVID wards which helped our finances. COVID practices like hand washing, PPEs, etc. became our daily routine.

We missed our friend’s weddings, relatives’ functions and could not go to our well-wishers’ deaths. Seeing all the attendants who did not even have a chance to say a final goodbye to their close ones, and patients who died with their dear ones not around broke my heart and made me pray daily, that this situation should never come again. Some are blessed and some are not.

Discussion

We had collected the data on the experience of around 12 nursing supervisors and nursing In-charges during this COVID pandemic. There were many sentiments in common, expressed about their experience during this battle against COVID. We are choosing a few to be highlighted here.

Theme 1: Shortages of staff

Nurses are a critical part of health care and make up the largest group of health care professionals. Nursing shortages lead to errors, higher morbidity, and mortality rates. In hospitals with high patient-to-nurse ratios, nurses experience burnout, and dissatisfaction and the patients experience higher mortality and failure-to-rescue rates than in facilities with lower patient-to-nurse ratios. In-charges and supervisors say that there was an extreme shortage of nurses as the admissions swelled to huge numbers. Some new nurses were not willing to work on COVID duty and some of them got sick. So, each nurse took on 10-15 cases in each shift. Supervisors faced many struggles, and confusion when planning staff allocation.

Theme 2: The struggle of wearing PPE

PPE can protect its wearer from contracting COVID-19 but it was very uncomfortable. If worn for too long, inappropriately, or not correctly as recommended by protocol, then instead of keeping the wearer safe it offers a false sense of security and can expose to infection. Staff has reported significant adverse effects including redness of the cheeks, nose bridge, and ears with N95 masks, dry mouth, fatigue, and headaches. Nurses may experience dizziness, dehydration and discomfort, and heat-related illnesses. Prolonged use of face masks may also cause hypoxia and fatigue.

Theme 3: Shortage of O2 and O2 devices

There were so many patients needing a high flow rate of O2. Oxygen delivery devices are recommended for all severe and critical COVID-19 patients. It was very difficult to arrange bed, O2 devices like ventilator, NRBM, and O2 cylinder in an emergency situation when patient numbers were increasing exponentially.

Nursing in-charges and supervisors stated that they couldn’t manage and arrange the O2 devices immediately. So staff needed to transfer patients from one to another unit as soon as possible and it was very difficult to explain that to their attendees.

Theme 4: Family ties broken

They were not able to visit parents, children, and family functions during this COVID-19 pandemic situation.

Sr. Arputha Mary said

“Whenever I think about it, tears flow automatically from my eyes. I couldn’t even imagine that situation. When I went home my kids try to hug me eagerly. I couldn’t even hug my kids. They begged me to hug them. It was a terrible situation. I have never been in such a predicament in my life. I just thought that kind of situation should never come to anyone anymore”.

Theme 5: We are proud to be nurses today

We are so proud to be nurses today. To see our profession in such action has been nothing short of miraculous. Nurses have always been on the front lines, have always sacrificed to heal and to make others feel better. But the last two years have brought out the best in every nurse, even when we thought we had seen that earlier during other crises.

We read stories, and we see it ourselves: Nurses are everywhere, taking risks when needed, fighting this new disease on our ER, floors, wards, ICUs, and ORs

We wish to paraphrase a commander of a war who had said long ago how the armed forces would defend their nation- “We shall not flag or fail. We shall go on to the end. We shall fight on our soil, we shall fight on the seas and oceans, we shall fight with growing confidence and growing strength, we shall defend our patients, whatever the cost may be. We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never give up, never accept defeat.”

We comforted people who were scared, helped people who were hurting, did without sleep so that others could rest more easily.

Thank you, nurses, for your wisdom, your strength, your service, your kindness. Thank you for being the best in the health field. You are serving the people with your leadership and caring.

Conclusion

The main strength of this story is that we collected data after the peak of COVID-19 cases in spring 2020. This timing allowed in-charges and supervisors to share their experiences during the peak of a COVID-19 pandemic.

Thank you, dear in-charges and supervisors, for your selfless service during these difficult times. You all showed such kindness and strength throughout these rough times. We are all so grateful to you. Also, we are so proud of you. Thank you for all that you do for which we shall forever be grateful.