Background
Coronavirus disease 2019 (COVID-19) was first reported from Wuhan, China in late December
2019 and was declared a global pandemic by the World Health Organization (WHO) on
March 11, 2020. As on November 23, 2021, the COVID-19 pandemic has infected more than
256 million individuals globally, leading to 5 million deaths and has disrupted health
care systems across the world.[1] Patients with cancer need prioritization of care, even during a pandemic. To continue
cancer care in the face of the pandemic, cancer centers needed to evolve pathways
to enable early identification of those with potential infections, and their high-risk
contacts, and segregate them from the other noninfected patients. This was essential
to contain the infection as well as minimize the risk of exposure to patients and
the staff.
Nursing staff, who have always been key frontline health care workers, have been instrumental
in the COVID-19 response worldwide, often at the cost of their own physical and emotional
well-being.[2]
[3] The Tata Memorial Hospital (TMH) is a grant-in-aid institution under the Department
of Atomic Energy, Government of India and a tertiary referral cancer hospital. Early
in the pandemic, the hospital was designated by the government as a COVID-19 hospital
for all patients with cancer. There is lack of data from an oncology center regarding
the impact of the double burden of COVID-19 and cancer on nursing staff in the face
of lockdown, manpower shortage, and personal challenges. In this article, we describe
the experience of nurses at the TMH who were at the forefront of the fight against
COVID-19, ably supported by others such as patient navigators, clinical research staff,
and administrators.
The Tata Memorial Hospital Experience
The Tata Memorial Hospital Experience
India reported its first case of COVID-19 on January 27, 2020, in Kerala, and the
first patient in Mumbai was diagnosed on March 9, 2020. The TMH began preparations
to deal with the pandemic in early March 2020. Several policies were implemented in
the hospital to mitigate the risk to staff, cancer patients, and caregivers to ensure
effective hospital functioning. The initial preparations included creation of a core
action group to review evidence, create and update standard operating procedures (SOPs),
and oversee daily operations. Nursing staff were an integral part of this action group
and expanded their services beyond the routine. The action group communicated via
a WhatsApp group, and key members of the action group met on a daily basis to review
the unfolding situation. The following areas were recognized for urgent action:
-
Screening patients and staff to identify those likely to be infected
-
Setting up of a fever clinic and facility for testing for COVID-19
-
Creation of isolation wards and stepping up the infection prevention control measures
-
Education, training, and audits
-
Management of infected cases and their contacts
-
Contact tracing.
Subcommittees of the core action group were created to look into each of these aspects.
A team of medical staff constantly updated the SOPs based on evolving evidence.
Subsequently, when TMH became a COVID-19 vaccination center in March 2021, nursing
staff took on the additional responsibility of managing the vaccination center.
Screening of Patients and Staff
Screening of Patients and Staff
One of the measures adopted since March 2020 was screening of patients and accompanying
persons at hospital entry points, and thermal screening for hospital staff. The screening
was undertaken by the frontline health care personnel, which involved mainly the KEVAT
(patient navigators), and the staff deputed from various departments of the hospital
such as preventive oncology, clinical research, nursing, and administration. The identified
frontline personnel were rendered intensive training on administering a COVID-19 questionnaire
and use of thermal screening to identify high-risk individuals, thus segregating the
COVID-19 suspects from others. Those who were identified as high risk- having history
of travel, symptoms, high body temperature-were referred to a dedicated “fever clinic”
for further evaluation. Others who were screened negative at the entrance were directed
to access regular hospital services. Entry access into the hospital was limited to
only one person accompanying the patient, extendable to two if the patient was on
a wheelchair. The frontline staff were trained to safeguard themselves from the infection.
This training included appropriate use of personal protective equipment (PPE), social
distancing, and hand hygiene.
Setting up of a Fever Clinic and Facility for Testing for COVID-19
Setting up of a Fever Clinic and Facility for Testing for COVID-19
A section of the main part of the hospital near the entrance was converted to a “fever
clinic” where screened individuals identified as high risk could be evaluated further.
Facilities for collecting swabs for reverse transcription polymerase chain reaction
testing, waiting areas for those awaiting the results of the swab, and separate entrance
and exit pathways to avoid mingling between suspects and other staff and patients
were also set up. Nursing staff assisted doctors in the fever OPD for sample collection.
Education, Training, and Audits
Education, Training, and Audits
We recognized that hospital staff, in addition to fulfilling their professional roles,
were also individuals who were concerned about their own safety and that of their
families. They were also key members of the community who could play a role in spreading
the right knowledge about COVID-19. Therefore, we started the process of training
hospital staff on various aspects of COVID-19. A group of nursing staff underwent
the initial training and then acted as trainers for the other individuals. These training
modules were conducted in small batches and included generating awareness about the
symptoms of COVID-19, and precautions to be followed by all (masking, physical distancing,
cough etiquette, and hand hygiene). In addition, they were taught about infection
control practices to be followed in the wards and critical care areas such as appropriate
use of PPE, measures to be followed while caring for those with COVID-19, and management
of waste disposal. Over the period of 2 months (March and April 2020), 919 nursing
staff and 1,322 ancillary staff received this training. In addition, 575 nursing staff
underwent online training in COVID-19 protocols to be followed. Periodic audits were
performed to assess retention of information and need for retraining. The nursing
department also undertook the task of training housekeeping personnel on infection
prevention and control measures.
Management of Infected Cases and Their Contacts
Management of Infected Cases and Their Contacts
Setting up of an Isolation Ward
The first step was to identify a separate ward which was converted into an isolation
ward to accommodate COVID-19 cases. Since the hospital had limited space, and needed
to continue cancer care, it was decided that only those with symptomatic COVID-19
or risk factors would be accommodated in the hospital premises. A separate facility
near the hospital was identified as an isolation facility for those with asymptomatic
or mild COVID-19, who did not have facilities for home isolation. Within the hospital's
existing facilities, new areas were set up by reorganizing various inpatient and outpatient
areas to create segregated space for COVID-19 care. An intensive care unit (ICU) facility
was created for the patients who needed ventilatory support and close monitoring.
A separate pathway for transport of patients with COVID-19 was identified, rooms for
donning and doffing of PPE were set up, and several trial runs were performed much
before we had our first patient to ensure that we were well prepared to safely manage
patients with COVID-19.
Tracing of Contacts
Identifying high-risk contacts of infected individuals is important to minimize the
extent of transmission. Nursing staff created a group which had individuals trained
in SOPs of contact tracing. The group efficiently conducted interviews of all possible
contacts to identify those at high risk. Those who were considered high risk were
quarantined at suitable locations. Initially, the quarantine facility was set up in
the hospital itself, while later on, other premises such as hotels and hostels were
used as quarantine facilities.
Testing/Retesting of Cases and Contacts
Nursing staff prepared databases of those in isolation and quarantine and arranged
for them to be tested at recommended intervals prior to termination of isolation or
quarantine. Since the guidelines for duration of isolation/quarantine and time point
for retesting were constantly evolving, the nurses adapted their SOPs accordingly.
Arranging Minimum Supplies for Those in Isolation or Quarantine
Recognizing that individuals who were isolated or quarantined may not have had time
to make preparations, nursing staff partnered with nongovernmental organizations to
prepare and provide basic hygiene kits to these individuals to tide them over the
initial period.
Changes in Working Pattern
Since COVID-19 management and cancer care had to be performed with the same number
of nursing staff, several changes were made to the working pattern. First, staff who
were high risk for COVID-19 (pregnant, multiple comorbidities, and immunosuppressed)
were given medical leave during the peak of the pandemic. A proportion of staff (around
40%) from medical and surgical areas were retrained in critical care skills and redeployed
in ICUs. Duty shifts in COVID-19 areas were drawn up to include staggered shifts so
that the duration of time spent in PPE was minimized. The “buddy” concept was brought
in where staff on duty alternately spent a part of their shift time attending to tasks
which did not require direct patient contact or the use of PPE. At periodic intervals,
staff were rotated from COVID-19 to non-COVID-19 duty areas, to avoid fatigue. All
attempts were made to ensure the physical and emotional well-being of the nursing
staff. [Fig. 1] outlines the nursing staffing pattern during the pandemic.
Fig. 1 Nursing staffing model during the pandemic. COVID-19, coronavirus disease 2019; ICU,
intensive care unit; PPE, personal protective equipment.
Nursing Education
Nursing education was also affected by the pandemic. TMH runs courses in oncology
nursing such as diploma in oncology nursing and masters in oncology nursing. In the
initial period of the pandemic, all the students were utilized in the clinical area
for patient care. Diploma oncology students were part of the screening team and MSc
nursing students were part of the contact tracing team. Online mode of training was
utilized for lectures to reduce the impact of pandemic on their learning.
Vaccination
TMH became a COVID-19 vaccination center in March 2021. Nursing staff allocated to
this center were sent to the COVID-19 vaccination center at the nearby municipal hospital
for training. The nursing supervisor also visited other hospitals to plan facilities
for the COVID-19 vaccination center at TMH. The responsibilities of nursing staff
at the vaccination center involved retrieving the vaccines from the central storage
area, maintaining the cold chain, administration of vaccine, keeping a critical care
unit ready for any emergencies, and maintaining a record of beneficiaries.
Challenges and the Way Forward
Challenges and the Way Forward
On April 12, 2020, the first case of COVID-19 was diagnosed in TMH. Since then, more
than 2,500 patients and 1,000 staff have tested positive for COVID-19 (until October
2021) ([Fig. 2]). Around 200 nursing staff have tested positive and 100 have been quarantined until
then. Some nursing staff have reported personal challenges such as social stigma from
neighbors and family or the need to stay away from home to avoid infecting family
members. Several staff have dealt with mental health issues such as anxiety and burnout.
Most of the nurses who used PPE for prolonged periods reported various types of injuries
and discomfort. With the pandemic extending for almost 18 months, fatigue has set
in, and there is the need to constantly reinforce and retrain appropriate behavioral
measures.
Fig. 2 Number of coronavirus disease 2019-positive staff in the Tata Memorial Hospital.
As COVID-19 cases plateau and we adjust to the new “normal,” cancer care has returned
to its usual volumes. The role of the TMH nursing team in dealing with the pandemic
has been acknowledged by the hospital administration as one of the most crucial aspects
of the overall response. Nurses presented their observations and learnings in hospital
meetings and in national webinars, to allow others to benefit from their experience.
Discussion
The WHO estimates that 80,000 to 180,000 health care workers could have died from
COVID-19 in the period between January 2020 and May 2021.[4] Several of them are likely to have been nursing staff. Bandyopadhyay et al looked
at COVID-19 infections and deaths among health care workers and found that among those
infected, nurses constituted the largest proportion (38%).[3]
The impact of the pandemic on the mental health of nurses has also been well documented,
with several studies reporting anxiety, depression, stress, burnout among nursing
staff.[5] A systematic review and meta-analysis looking at psychological distress among health
care providers during COVID-19 in Asia found that more than one-third of health care
providers suffered from anxiety and depression, the likelihood being higher with female
gender and nurses.[6] Lack of human and physical resources and the number of colleagues infected with
COVID-19 were the strongest predictors of stress, anxiety, and depression among nurses.[7] Sharma et al surveyed nurses at the frontline in government hospitals across India
and found that 12 to 14% of them reported anxiety and depression among frontline nurses.[8] Nurses have been at the receiving end of bullying and social stigma due to the perception
that they are carriers of COVID-19.[5] In a study among health care workers in India, Radhakrishnan et al found that 70%
of nurses reported a stigmatizing experience during COVID-19, and that being a nurse
and working in a clinical area were more likely to worsen this experience.[9] Most of these reports are from the initial period of the pandemic where transmission
was less understood and fear was high. It is to be hoped that several months into
the pandemic, and recognizing the vital role that health care workers have played,
such problems and stigma do not exist anymore.
The use of PPE is associated with problems such as pressure injuries, headaches, sweating,
disturbances of vision, and difficulty in breathing. It has been estimated that three
out of four individuals who use PPE are likely to have adverse events related to skin.[10] Nurses, due to their long-duration shifts and fixed postings in COVID-19 wards,
are more likely to experience such problems. Wearing PPE for longer than 4 hours has
been identified as a significant factor for adverse events, and limiting the duration
of PPE to less than 4 hours could be the solution.[11]
The training of nursing students during the pandemic has also been affected, with
the switch to online classes. Their clinical experience has been limited by frequent
postings in COVID-19 wards and ICU. In a systematic review of studies from around
the world, Mulyadi et al found that nursing students had high rates of stress, anxiety,
fear, depression, and sleep disturbances during the pandemic.[12] In another study, more than 90% of nursing students reported a lack of proficiency
with the use of internet and online teaching methods.[13] It is essential that their skills and confidence should be reinforced in the remaining
part of their training schedule.
Nurses, whether posted in wards, operating rooms, or ICUs, have always been a part
of a multidisciplinary team and recognize the importance of teamwork through collaboration
and good communication. During the pandemic, the nursing team at TMH has taken teamwork
to a new high and worked in close partnership with several other departments—patient
navigation teams, administration, medical staff, clinical research staff, and many
others, to ensure smooth functioning and better outcomes. Their combined efforts have
proved that it is possible to continue routine medical care while simultaneously managing
the COVID-19 situation. For conditions such as cancer, where any delays in diagnosis
or treatment affects patient outcomes, this learning is important.
Conclusion
The WHO had designated the year 2020 as the “year of the nurse and midwife,” in honor
of the 200th birth anniversary of Florence Nightingale. It is appropriate that in
this year, nurses have been the champions in the battle against COVID-19. However,
in the course of this battle, nursing staff have faced several challenges which need
to be addressed to ensure their continued well-being. Hospital administrations should
recognize the critical role that nurses play in crisis situations and empower them
while they deliver important aspects of the overall response.
