In a new series for the hub, Martin will be interviewing healthcare professionals from various specialties to capture their experience and insight during the coronavirus pandemic. Learning from frontline staff is crucial, now more than ever. Prior to a predicted second wave hitting us, the government and leaders must listen to what has gone well but, most importantly, not so well for both staff and patients.
Martin is a passionate nurse working on a covid unit and wants to promote learning to ensure patient and staff safety. This initially started as a way of connecting and not feeling alone but what Martin has found is that there are many voices that need and want to be heard but just don’t know how to speak up and out. In all of the interviews the healthcare professionals wanted to remain anonymous which is indicative of their fear of reprisals from their organisation.
In this first interview, Martin interviews a new student district nurse who has been working within the community in the South West. Their role involves supporting care homes with end of life care and assisting in keeping people with long term conditions at home.
Questions & Answers
Martin: Can you tell me about your experiences on the frontline during this pandemic and the patient safety challenges you have have seen?
Student district nurse: Throughout this pandemic, I have been a student seconded to complete the Community Specialist Practitioner Course (District Nurse Training). Therefore I have not been completing my normal role of community nurse out seeing lots of patients every day. Instead I have been working alongside more senior practitioners developing my management and leadership skills and, from this perspective, the pandemic has been an interesting though worrying experience.
Due to this ‘supernumerary’ status I have had time to reflect and examine from an ‘outsiders’ point of view within the team which has been highly beneficial. I would say personally that we as a community team have not been on ‘the frontline’. I feel this applies more to the acute services in medical assessment and intensive care provision. However, community services have unfortunately been at the poorer end of support during this pandemic, with patients being discharged to care homes for example prior to any testing. This has sadly had the effect of causing pockets of ‘viral infection’ within already at-risk patient cohorts.
One of the more difficult aspects as a nurse has been accepting the decisions of others and the decisions made around care progression. This has often led to internal ethical dilemmas.
Martin: Could you give an example of this?
Student district nurse: Yes, I recently saw a 94-year-old man with advance dementia. He had a history of chronic obstructive pulmonary disease (COPD), cardiovascular disease, a long-term urethral catheter in situ and his COVID-19 swab result was ‘inconclusive’:
- Develops a temperature.
- No other definite COVID-19 symptoms.
- O2 saturations drop to 88% - no baseline available so could be normal for him.
- Auscultation inconclusive due to limited ability to assist in examination.
- Patient becomes agitated as I am wearing a mask and goggles, gloves and a gown; he probably has no idea who I am or what I am asking of him.
- He is also hard of hearing.
- His swallow has deteriorated and he is now on thickened fluids.
- He has a chesty cough.
- He has become more agitated and shows non-verbal ques of discomfort.
- PRN meds and syringe driver script are already in place.
- Patient as has already been deemed to be for palliative care by GP and family.
- He has a DNACPR.
So this could be COVID-19, lower respiratory tract infection (LRTI), community acquired urinary tract infection (CAUTI) or just end of life dementia deterioration. We can’t supply him home oxygen due to COVID-19 and this would likely be of little benefit. A catheter specimen of urine (CSU) has been sent to detect for possible CAUTI. We cannot get sputum sample and are limited in ability to medicate due to his agitation and also swallowing issues. No covert administration plan is in place, it’s Friday afternoon and these take time to establish and authorise with the care home.
What do we do to support the patient? He could be treated and improve but we cannot admit as not appropriate and if he was accepted for admission, he would likely die in hospital.
So a decision is made with senior clinical staff around quality of life (QOL) issues and current situation to start a syringe driver as per new policy to reduce need for multiple visits to give stat doses. We give him midazolam for agitation and morphine to assist with relaxing breathing and possible pain. The patient then dies before the CSU result is even back from the lab.
This is not an uncommon occurrence.
The ever-changing guidance around appropriate personal protective equipment (PPE) has not helped in maintaining staff and patients safety at all – one day it was a mask and gloves and plastic apron, then thumb loop and surgical mask and goggles and gloves, then backwards, then no goggles. To my knowledge one or two members of the team I work within have been fit tested for FFP3 masks and now I believe they have actually stopped fit testing all together due to the fact that there are very few situations in which we require these. However as a member of staff attending a care home to review dementia patients for four or five hours and there being 20 confirmed cases within the home I do feel that using a thumb loop gown and surgical mask hardly seems enough protection for either staff or patients.
Some homes have had care staff with no PPE, some with too much, this is then mixed with differing individuals personal views who then choose not to wear the PPE supplied. It has been a difficult time to be objective and believe that ‘everyone is pulling together’ in situations such as this.
Additionally the service has been reduced to ‘essential visits’ only. This has been both a blessing but also a worry for the future. Where have the patients with COPD who call the Clinical Lead for advice been going for this guidance? Has ‘Doris’ the 86 year old diabetic who was deemed safe to self-administer her insulin actually been completing this correctly (example only)?
Only time will tell regarding the fallout from the virus and the impact it will have had on the many isolated individuals within the community cohort.
Martin: What resources have been made easily available to you?
Student district nurse: Advice from the trust has been widely advertised around mental health support and guidance, along with contact numbers for the relevant services. The redeployment of many of the ‘specialist’ nurses has been beneficial within the local team as this allowed those long-term complex patients with diabetes or ‘leaking legs’ to be reviewed by a specialist diabetic nurse or lymphoedema nurse who were able to review and assess with ease. Though these specialities were open to us before, they were not working in such a closed patient group with a much larger waiting list of patients to review – so for these patients this service has been highly beneficial.
Martin: What have been some of the positives/negatives you have taken away?
Student district nurse: That in certain situations decisions can be made quickly and red tape can be cut. This can be of great relief in some of the more time intensive assessments; however, the upshot of this is whether these assessments would have identified additional health needs or a different approach to care.
I believe that the staff have had to get on with the work allocated and less time has been wasted within the day around discussion; however, has this come at the expense of the patient no longer having that chat that they look forward to with the nurses visit; or perhaps a health issue not being raised as the patients know the ‘staff are busy’. In addition, has the support from staff towards each other been effected? Supervision hasn’t really been occurring in a time when it would be most valuable. I am lucky that within my current position this has continued, but for many it hasn’t.
Martin: How well have you been supported by your managers?
Student district nurse: I think the management teams have been put under a huge strain by the entire situation. I cannot really comment on this too much as my manager is based in another team as I am a seconded student; however, I believe the management in the trust have done the best they can to support staff and provide a unified vision of being in it together.
Martin: What skills do you have to better enable patient safety and how did you acquire those?
Student district nurse: Through my training the additional skills learnt around physical assessment and also ‘bigger picture’ thinking has been highly beneficial in this time. Being able to advise staff around you, including carers, of care expectations going forward and being well informed to do so had its benefits.
Martin: How have you coped?
Student district nurse: I believe that I have coped by doing the best that I can for those under my care, working towards their best interests as often as is able and to ensure that I turn off at the end of the day when I get home. Distancing from those around you has been complicated and taxing, I am lucky that I have been able to remain with my partner and child throughout the pandemic; I don’t believe I would have managed without their support. The ability to have time to reflect again comes into play here, only through this practice can we continue to analyse and grow as practitioners to improve the service we provide our patients.
Reflections and final thoughts from Martin...
During this interview and the other interviews I will be sharing, it is clear to me that although everybody's experience was different, the patient safety issues faced are fundamentally the same: lack of resource allocation leading to unsafe practices for both patients and staff, teamwork processes differing daily causing confusion and unsafe infection control procedures.
Formal and informal leadership actions can directly impact on poor patient management. Failings of corrective actions can leave both staff and patients feeling untrusting towards care organisations and providers.
As this interview demonstrates, frontline workers have had patient safety at the forefront of their minds during this pandemic; however, it is failings in the system that can lead to unsafe practice that, in some cases, can jeopardize patient safety.
Would you like to feature in one of our interviews? We'd love to hear from other frontline contributors.