Nursing in the Age of COVID-19

In her more than 11 years as a registered nurse, Mary McFarland has never seen anything quite like what she and her nursing colleagues have to do to care for Covid-19 patients.

McFarland is a senior clinician at UPMC Presbyterian’s intensive care unit, usually an administrative job that oversees the ICU. But the unprecedented nature of Covid-19 has led to dramatic changes for McFarland and other nurses in the Pittsburgh region.

Changes to age-old nursing routines begin immediately upon entering a hospital, where every employee is screened for the early symptoms of the silent virus. At UPMC Presbyterian, an entire ICU has been set aside to treat the critically ill with Covid-19. And when in that ICU, where patients have struggled daily to breathe and to live, even the smallest move can be a matter of life and death for the caregivers themselves.

“It is a completely new set of skills,” said McFarland, who helps coordinate the nursing care and has worked directly with Covid-19 patients.

The importance of every step in the process has been amplified, from cleaning and hygiene regimens to the careful process of putting on and taking off the head-to-toe personal protective equipment that helps protect care providers from catching Covid-19. It impacts interactions with the patient, as well. There are specific steps that must be taken, all the time, to make sure everyone remains safe. UPMC has instituted a nurse-observer system, where specialists carefully monitor the donning and doffing of PPE.

“If only one step is forgotten or done out of order, it could put the nurse at risk for exposure, so it gives a level of extra comfort for the nurse observers to watch everyone who goes in and out of the room to keep everyone safe,” McFarland said.

‘Whole health care dynamic has changed’

McFarland and many other nurses are on the front lines of the war against Covid-19. And unlike the wars against infectious diseases of the past, this one has changed so many things about how nurses do their jobs.

The Pittsburgh region, with its relatively light level of Covid-19 patients, has thus far been spared the unimaginable crush of victims that marked New York City, New Orleans and Detroit, among others. But in the early days of the crisis, no one knew that would happen, and the hospitals couldn’t take the chance. And this has remade, at least temporarily, what it means to be a nurse.

“Over the past two months, the whole health care dynamic has changed,” said Diane L. Puccetti, chief nursing officer of St. Clair Hospital.

It’s not just having to don extra gear and being supercautious. Nurses, even those not directly dealing with Covid-19 patients, also are now navigating health care systems that have radically changed their operations.

Nonemergency procedures and surgeries were eliminated, taking with them a large bulk of the patients and the work (elective surgeries were just permitted by the state to resume last week). Visitors are banned in all but a handful of circumstances. Entrances are closed. Employees have to be screened and their temperatures taken before they are allowed to go to work. And some health care workers have been sent home for either exposure to or confirmed cases of Covid-19.

One of the major consequences has been a redeployment of nursing staff. With most operating rooms and other parts of the hospital temporarily paused, health systems and hospitals moved nurses to pressure points in the Covid-19 era: Working the entrances to screen employees, serving as roving nurses on floors they don’t usually work and filling in for ICU and step-down unit nurses who either take a meal or other break.

Excela Health, St. Clair Hospital and WVU Medicine, among others, have cross-trained nurses and nurse anesthetists to work in critical care and medical-surgical units when they’re needed. It has been a constant, shifting mode of staffing that combines training and deployment to meet the needs of the hospitals as they arise.

“It’s become more vigilant for us during this crisis, but it’s a balance of meeting the patients’ needs, whatever they are, as they present,” said Helen Burns, chief nursing officer at Excela Health.

At WVU Medicine, 300 to 400 nurses are learning how to work in the ICU in case, in the future, they will be needed to deal with a surge of Covid-19 cases, according to VP and Chief Nursing Officer Doug Mitchell.

“You don’t make an ICU nurse in a few weeks, but you can certainly get a nurse or a CRNA (certified registered nurse anesthetist) up to speed if you had to double your capacity by working side by side with seasoned ICU nurses,” Mitchell said.

Big weight on the shoulders of caregivers

Even on the wards themselves, the work of nurses has changed. Instead of a single RN being responsible for a few patients, which is the typical routine, some hospitals have moved to more of a team approach where an RN may be in charge of a larger number of patients and have other nurses working under him or her.

That team approach — and the sense of community among the nurses and other health care providers — is solidifying a sense of camaraderie amid the Covid-19 caregivers.

“We need to be here and meet the needs of our community, and that means we have to keep each other safe,” McFarland said. “There really has been an incredible level of teamwork between everyone here on our unit.”

Allegheny Health Network also has fostered a sense of teamwork by ensuring that its nurses don’t float, mostly staying in the familiar surroundings of the hospitals they’ve worked at. Claire Zangerle, AHN’s chief nurse executive, said the health network’s nurses have held up well amid the stresses.

“You feel the weight, and the pressure of what’s happening right now is evident,” Zangerle said. “You may not be taking care of as many patients, but those patients you are taking care of, whether they are Covid-positive, Covid-suspected or Covid-possible, that’s a big weight on the shoulders of caregivers.”

Death is nothing new to nurses, particularly to the men and women who work in the ICU. But Covid-19 has brought new challenges and limitations to end-of-life care, especially the men and women in their final hours who can’t have visitors. That’s not only true for Covid-19 patients, but also other terminally ill patients.

“All of us, our thoughts are with the families who can’t be here to comfort these patients,” McFarland said. “Our patients that are awake and interactive, they’re in a room with the door closed. It’s very lonely.”

McFarland said ICU nurses have been making use of technology, particularly FaceTime, that allows patients and their families to be connected.

“Nurses are being present with their patients and sadly, but very inspirationally, are spending time with their patients in their final moments of their life, nurses sitting down at their patients’ bedsides, holding their hand, telling them that they’re not alone and saying they’ll be with them,” Burns said.

Linda Homyk, VP and chief nursing officer of Heritage Valley Health System, said nurses have stepped up regular phone calls and video chats with their patients and families, sat quietly by the bedside or been there some other way.

“The biggest impact has been being the eyes and ears for the families and taking extra time to provide the emotional support to both the patients and the family members,” Homyk said.

Mitchell said that now more than ever, nurses are finding ways to take care of their patients who have a higher level of anxiety.

“We’ve doubled down on the idea that we’re here not just to provide the high-tech care, but we are there to provide comfort and compassion to our patients,” Mitchell said.

At an AHN hospital, where there’s a one-visitor limit for end-of-life patients, the nursing staff made an exception for two people who had traveled far to see their loved one dying of Covid-19.

“Our nurses took care of all the PPE they needed, went outside of the hospital and put them on the visitors, so they could go and say goodbye to their loved one,” Zangerle said. “That’s above and beyond.”

Nurses at every health system have helped, through the use of video and audio on smartphones, to allow loved ones who aren’t able to be there to still be connected to Covid-19 patients. One loved one, who was ill herself, couldn’t come to the bedside of her mother at an Excela Health hospital. The nurse connected the patient and her daughter by phone, putting the phone by the pillow so she could hear in her final moments her daughter’s voice, telling her how grateful the daughter was for her mom.

“This crisis has afforded the opportunity to go beyond the science, the tasks, the technology of nursing,” Burns said. “This crisis has really given the nurses the ability to display their humanity and really practice the art of nursing.”

‘Each day one at a time’

And what happens at work, now more than ever, has its impact on the nurses.

Each has his or her own ways of handling the stress and the fears, which all health care workers have, of the possibility of not only becoming ill with Covid-19, but also perhaps bringing it back to loved ones. Some health care workers have made the choice to stay away from home until the threat has passed, and UPMC, AHN and WVU Medicine have provided either access to empty dormitories or hotel rooms.

McFarland credits UPMC and its experts with arming them with the equipment and knowledge to be safe. She and her husband have often talked about the potential threats to her, to them and to the couple’s daughters, ages 2 and 3. They’re comfortable that since she’s able to take the necessary precautions and have the proper PPE, that she’s comfortable in going home after her shifts. She said she finds comfort in home, and being with her husband and kids allows her to relax, even in these stressful times.

“I think when you think of it in those (stark) terms, yes, it seems overwhelming and terrifying,” McFarland said. “But personally I have been trying to take each day one at a time. It seems a lot more manageable that way, and I’m able to stay more positive throughout the whole situation.”


By Paul J. Gough  – Reporter, Pittsburgh Business Times