PORTRAITS IN PALLIATIVE CARE
Nurse Manager Nancy Ward on impact of COVID-19 on palliative care staff and family members
“We are doing our best, the same way everybody is, to be safe and follow the rules, so hopefully COVID will pass and we can re-open our doors fully to welcome all the family members so that the patients’ journey here is not just with staff, but with their loved ones. We want to be able to do what we used to do in our new reality.”
By Devon Phillips. According to Nurse Manager Nancy Ward at the West Island Palliative Care Residence (WIPCR), the arrival of COVID-19 has resulted in radical changes in how the Residence operates and interacts with the families of patients at the end of life. While the actual care provided to patients by staff remains stellar, greatly reduced support from family members and volunteers (because of social distancing requirements) has placed additional pressure on nurses, and has negatively impacted on the end-of-life journey for families and loved ones.
Q: Tell me about the WIPCR and your role as the Nurse Manager.
A: The WIPCR will soon be renamed the Teresa Dellar Palliative Care Residence. At the end of January, we consolidated our two facilities, Stillview and André Brunet, so now we are all under one roof. We have a 23 bed capacity, and we accept patients from all over our territory, which includes the West Island, Dorval, Lachine, Lasalle and south to the Ontario border.
As Nurse Manager, my role is primarily administrative. I do not work on the floor per se but will assist with nursing tasks and care when needed. I troubleshoot, I am a resource person and a consultant. I do all the employee scheduling, assist with policy/procedure updates, liaise between doctors, nurses, PABs, supportive care - a little bit of everything. Our team consists of approximately 50 RNs, LPNs, and PABs, and we are now starting our summer program with nursing students.
Q: So it’s been a big year with the transition from two palliative care facilities to one and then the arrival of COVID a month later.
A: It’s been a big challenge. We had to align the practices of two teams and that was a tough change for many of the staff but we are working well now as one team. But then we throw in COVID. Just one month after the consolidation was complete, the pandemic hit. 2020 has been exciting!
Q: What are some of the challenges at the Residence now that COVID is on the map?
A: The biggest challenge was banning visitors from the Residence. We needed to do this but it resulted in emotional turmoil for the staff and for the families. Now that we have opened up a little bit, we can have some family members in, but it is limited and that is very hard for families. We just had a case with a man in his 60s who was dying and he had a wife and three daughters. We are only allowed to have three people in so how do you make that choice? Families can visit from the patio but that is heartbreaking because you see people just looking at each other through a glass door and we want to say, “come on in” but we can’t.
Q: Have you had COVID cases at the Residence?
A: We have been very fortunate because we have not had COVID cases here. The staff has been well and we have adapted our environment in order to keep everyone well and safe and keep our residence “cold”.
Our policy is to test patients upon admission and isolate them using full PPE until we get the results.
We did have one woman who tested positive even though we did not suspect she would. This was a little lady who was still dancing around in her room, completely asymptomatic. We had to transfer her to a CHSLD designated for COVID cases. This was very hard for her but we had to protect the others. Once she has tested negative, we will look to readmit her.
Q: You mentioned you have had to adapt to COVID. How are the staff coping with the changes in how they need to function?
A: It was extremely stressful in the beginning because we did not know what was going on. What we would decide on Tuesday was not the same Wednesday because we were following government directives that were changing every day. The team, at this point, is in a good place. They feel supported and safe. We have all the protective gear we need and we have rules in place. In the beginning, there was a lot of fear and anger. At one point, we were not allowing any visitors and this was very upsetting. To not allow somebody to see their loved one took its toll on the nurses. Sadly, we had to do what we had to do. It was a good two months of extremely high stress levels.
Q: How did this added stress manifest in the nurses?
A: There was a low mood, a lot of tension, and the usual camaraderie and joking around was not there. We had a few cases where family members did not tell the truth. One patient’s daughter came in from the States and lied saying she came from Ontario. The nurses voiced, “how could she do this to us,” and they were angry. In that case, we sent the patient back home with help and it all worked out in the end as it was the wish of the patient to die at home, but the nurses felt betrayed. There was also frustration and blame as if the managers were not doing enough but we could only do what we could do. We were not able to test people upon admission because the government did not allow it. Our hands were tied about many things we wanted to put in place.
The other issue was that we had a shortage of PPE (personal protective equipment) because at the beginning of the pandemic, everybody was hoarding.
Q: How did you manage to obtain all your PPE?
A: We were able to purchase some and we received donations. There was a group of volunteers who were sewing masks. Community businesses offered procedure masks which we accepted gladly. People were making head coverings for us; we looked like we were in the ICU! Somehow, we managed. We had to adapt from one day to the next.
Q: Are you able to follow the guidelines to avoid transmission, for example by keeping distance, within the Residence?
A: At this point all staff walk around with masks, even with each other, because at the nursing station we cannot maintain the required distance. It is a weird feeling. I walk by and smile at someone and say, “I just smiled at you” because we cannot see those smiles anymore. The physical distancing is hard. We used to hug each other and pat each other on the back but we cannot do that now.
Family members can visit but not as much as they want and not how they want. When someone is dying, we allow 24-hour-a-day visits but only two people at a time with a max of three on the list of essential visitors. What if there are four children? Who decides which two visit? If we let in those two other people then we are letting in two people who may have five contacts within their families each, then another five and another five, and that is where the fear lies. Even bringing in volunteers to help out, we calculated would average another 50 people a week coming into the building and that is a big footprint. It is frightening to open up the doors again.
The Hudson hospice has had to close. A few weeks ago three or four nurses tested positive and then some patients as well. It means that 12 palliative beds in our area have been lost. Our capacity is completely full. We cannot have COVID here. The domino effect of one team member testing positive will be monumental. As tragic as it is, we cannot allow all these people back in the building because we cannot get sick. We have to take care of our patients.
Q: Has COVID changed the nature of communication in the Residence?
A: Totally. It’s changed how we interact with the family. We used to hug family members when they were crying and now we cannot. Sometimes they stand outside crying, looking at their loved one dying and we cannot do anything about it. That is the part that I think the nurses find the hardest. Caring for the patients is the same - they still get the best care, but we cannot do the family interactions as we used to.
I had an employee whose father- in-law just died of COVID and she said to me, “I just realized what the families are going through. We cannot have a funeral. We cannot bury my father-in-law because those who die of COVID must be cremated. His wishes are not being respected. I finally get why the families are so angry with us.” We deal with a lot of this anger.
Q. That must be tough. How have you been able to keep the morale of the nurses up?
A: Lots of food! People have been generous sending meals in. I found that once the anxiety level had decreased enough, we started joking around again and doing the things we used to do, just letting some steam off. We have staff who are mothers of young children who are afraid of bringing COVID home so we have adapted the schedule decreasing the number of days in a row that they work. Everyone is home schooling so the stressors at home are also increased. It’s a hard time for people. On the other hand, it is also a great time because you are seeing the importance of your family bringing different closeness and bonding.
Q: I understand at your Residence, volunteers fulfill many important roles. What is happening with the volunteers given the COVID pandemic?
A: We lost our volunteers. With COVID, we cannot bring anyone extra into the building. Yes, paid people can do the job, but we miss the extra person that can sit with someone, help in the dining room, help in housekeeping; there are just so many roles and the volunteers are not here anymore. A fair amount of our volunteers are over 70 and the directive for that age group is to stay home. There are more demands on the staff now because families and volunteers are not here.
Q: is there a risk of compassion fatigue or burnout for your nursing staff?
A: Very much so. One of the first signs is physical injury. This happens because the nurse is tired. Very few people are comfortable saying, “I am not coping. I am anxious, I am depressed.” People still consider this a weakness and it is not. The team give a lot both physically and emotionally. The physical injuries - back, shoulders, neck – all of this is the stress they are experiencing and one wrong move when they are taking care of a patient and they will injure themselves. At this point, I have 15 people who are off on either medical leaves, maternity, or because they have a second job and we don’t want to risk cross-contamination. The majority of the staff reduction happened in the past two months since COVID.
Q: COVID has had a big impact on staffing then?
A: Absolutely. I have five people who work elsewhere where there is COVID and we have had to stop them from coming to work here. We have had constraints we have never experienced before. I don’t know how we are going to hire new employees now because most places have COVID. Many PABs work in long-term care and I cannot hire them here. And, of course, the loss of the volunteers has had a huge impact.
Q: We are all hoping that this resolves soon and people can return to their work as before but I hear a lot of people say it’s a new reality and things will not return to the way they were. What do you think?
A: I agree. I think this is what we are going to be doing for a long time. Our new normal is that you are going to wear a mask when you go out, you are not going to shake hands with people, we are going to do a lot of virtual meetings because there will be a second wave. We can see it happening. Just last weekend on my street, people were having parties with more than three families, more than 10 people, because everyone is just fed up. I really think it will be with us for at least another year.
Q: Looking ahead a year from now when you say we’ll still have COVID and will have to maintain this change in practice, will the new building serve you well?
A: Yes. Everything has been well thought out in terms of providing quiet spaces for staff and quiet spaces for families. We have enough room that we can ask one family to go into a separate one area and physical distance. I think standard practice is going to be that people will have to be tested and then isolated while waiting for results. We went through that a few years ago when MRSA and VRE were the big infections. Now it’s COVID-19.
Q: The WIPCR has always had a commitment to provide the best care to patients. In the context of COVID-9 or other pandemics, what other adaptive strategies are required?
A: At the beginning of the pandemic, we set up a hot line with our supportive care team for the families to call directly rather than calling the nursing station because the nurses were much busier than usual and could not answer the phone. We do see and support family members but only with social distancing while all wear masks. I have to say we are missing the human touch. The supportive care team is integral to the care and we are leaning on them. Ways to hold bereavements groups, possibly via Zoom, are being explored.
COVID also impacts our fund raising events. The fund-raising team is exploring options to hold our events safely.
Q: You are doing an incredible job by balancing the public health regulations to protect people and by proving the best care you can at the end of life. Hats off to you and your team for pulling together.
A: Thank you! Everyone who works here is here for the right reasons because, if they were not, they would not be here. People here stay and do what they need to do each day and because their core values are right, it is working. The nursing team are there for each other.