Innovating to Assure Safety with Limited PPE Supplies

In response to the COVID-19 pandemic, nurses and clinical Colleagues faced a shortage of N95s and personal protective equipment (PPE) supplies. The safety of Colleagues while caring for sick COVID-19 patients became one of the highest priorities of the organization, especially in light of an unknown and emerging disease. Hospital leaders worked diligently to acquire as much PPE resources as possible, while adapting protocols in response to shortages, evolving clinical recommendations and emerging research.

N95 Respirators

In March of 2020, N95s were kept in paper sacks to be stored between uses and used for only one day, however little was known about when new supplies would be available, how many patients would need to be cared for and when new surges would arise. Measures needed to be taken to assure that Colleagues had availability of needed N95s for the long haul. Leaders considered how to safely extend the use of N95s while assuring safety.

Using the best available evidence and PPE supplies, teams implemented processes to keep Colleagues safe:

By May of 2020, hundreds of nurses and clinical Colleagues had been fit tested and new N95s “kits” were deployed.
Kits contained multiple N95 respirators and small paper sacks used to rotate use after a “rest period”. This helped to assure N95 availability during what appeared to be unpredictable supply and demand conditions.
Designated areas on each unit were set up to store and organize PPE kits.
N95s were obtained from the Strategic National Stockpile, special vendor orders, and community donations.
Goshen eventually acquired more than 8 different N95 types which allowed Colleagues to move back to the traditional single usage pattern of N95s in most areas by the end of 2021.

Positive Airflow Personal Respirators (PAPR)

Positive airflow personal respirators (PAPR) were acquired for Colleagues who did not fit into the various N95s that were available. PAPRs had been very rarely used before the COVID-19 pandemic and now were in much higher demand, particularly in ICU and ER settings. Teams raced to acquire more PAPR supplies, developed daily cleaning and storage solutions despite constraints, and rapidly trained front-line Colleagues who were depending on these resources.

Elastomeric Respirators

Elastomeric respirators were not familiar to any healthcare Colleagues prior to pandemic unless they had worked previously in construction or the military. However, considering supply limitations, Colleagues were interested in exploring these devices to see if they would offer improved comfort and safety. In November 2020, elastomeric respirators were made available to Colleagues in front-line clinical areas. Fit testing and training were provided for their use, cleaning, and storage. While very different from other forms of PPE, individual Colleagues found them to provide an additional measure of comfort and safety.

Much credit should be given to the materials management Colleagues who made daily calls to obtain supplies, fit testers who assured the safety of each Colleague, leaders who organized, retrieved, and collected supplies, and each Colleague who daily donned their PPE--all working together to assure the ultimate priority of safety for both the Colleague and the patient. Colleagues were able to find confidence in using PPE while caring for extremely sick patients and persevered through difficult situations.

Innovating to Maintain Family Communication

Clinical nurses were faced with significant challenges in 2020 to balance the safety of families and visitors with the need to provide education and reassurance both during the patient’s hospitalization and at discharge. Visitor restrictions, implemented to prevent the spread of COVID-19 during hospitalization, created additional burden for all clinical Colleagues, patients and their families and loved ones.

Recognizing the essential need for reassurance and information for families and patients, nurses adapted the use of technology to implement virtual discharge teaching, Zoom calls and Facetime visits with patients to improve communication. Nurses worked diligently and quickly to provide daily communication and outreach especially during times of visitor restrictions to make sure that the families were aware of the patient’s progress and plans for their care. Nurses from Childbirth Education and the Center for Cancer Care provided telephone updates to patient’s families, giving them much needed information about their loved one, while allowing the patient’s nurse to focus on care.

Very early in the pandemic, virtual video chats facilitated in the Arbor rooms were initiated for patients to participate in discharge teaching. A Zoom option was available for families to access the chat from home. Recognizing the need to connect families directly with patients, nurses also implemented iPad Facetime communication for families. This required the deployment of new technology, training for many Colleagues and additional work for clinical Colleagues to connect these resources, often for debilitated patients. The result was reduced isolation and improved connection and support for patients and families during difficult times.

These electronic connections become increasingly meaningful over the course of the next year, as many patients faced end-of-life distanced from their loved ones. While held by safety constraints, our nurses, chaplains, and numerous other Colleagues demonstrated their strength and humanity and led family after family through times of difficulty and loss using innovation.

Nursing Research

Goshen Nurses contributed to new nursing knowledge by conducting and participating in 2 IRB-approved nursing research during the pandemic.

The Perceptions and Experiences of Newly Licensed Registered Nurses During a Pandemic.

Study design:

The study took place February through October 2021, led by Principal Investigator (PI) Deborah Gillum, PhD, MSN, RN, CNE, Nurse Research Specialist.

The purpose of this phenomenological study was to explore the perceptions and experiences of newly licensed registered nurses (NLRNs) who transitioned to the professional nursing role in the acute care setting during the COVID-19 pandemic. Phenomenological analysis is a qualitative method that seeks to answer the lived experience of an individual or group, in this case, newly licensed RNs.

After informed consent was obtained, demographic data was collected to describe the sample adequately. This data included age, gender, ethnicity, marital status, degree earned to become an RN, and length of time employed as an RN. The remaining data was collected via one-on-one semi-structured interviews conducted in a quiet, distraction-free environment, such as a private conference room or office that ensured social distancing or via Zoom. The interviews were scheduled at the convenience of the PI and the participants and were approximately 60 minutes. The interviews were conducted when the participants were not scheduled to work.

The interviews were recorded and transcribed verbatim for thematic analysis. The PI also took notes during the interviews to merge observed non-verbal communication with the transcripts of the verbal interviews. After data was collected, the data was reviewed and deconstructed for analysis to allow for coding of patterns and themes within the data. All data was de-identified and reported as an aggregate.

Participants were recruited using a convenience sample and inclusion criteria will include RNs who are over 18 years, speak English, have been licensed as RNs for less than 18 months, have participated in the Goshen Hospital nurse residency program, and are employed in the acute care setting at Goshen Hospital. Exclusion criteria include RNs previously licensed as LPNs, or RNs who primarily work in the non-acute care setting.

Study results:

Participants included:3 ADNs; 3 BSNs. All female. Age range 22-32, mean 25.6 years; 4 nursing units represented. RN licensed between 13-16 months.

The key perception themes identified of the NLRNs during the pandemic were fear and anxiety; feeling overwhelmed; grappling with the differences in expectations and values of the nursing profession; transitioning back to novice when the COVID surge declined; and the importance of faith in coping.

The key experiences that were the most influential with the NLRNs were the connections made in the family/patient relationships; the debriefing and support of the residency program; essential peer support from other NLRNs and seasoned experiences, and the support systems from their own family and friends.

Discussion and interpretation of the findings:

The NLRNs described the last 18 months as “awful and rewarding.” They have experienced a very stressful entry into practice and are managing it with the support of their fellow NLRNs and seasoned mentors. The residency program allowed the NLRNs to debrief and process in a safe environment while providing the necessary encouragement for them to continue to provide care to these challenging patients and to remain at the bedside.

These NLRNs have become specialty nurses with highly specific types of patients yet feel inadequate in caring for the types of patients that is the typical patient population on their units. They have met the extensive needs of these patients and their families at often a high emotional cost to themselves.

Implications of the findings and recommendations to the organization:

NLRNs are under tremendous strain, and providing opportunities for peer support and debriefing, as well as encouraging self-care, are essential to supporting them as they transition to, and choose to stay at, the bedside.

Compassion Satisfaction, Burnout, and Secondary Traumatic Stress in Nurses in a Small Community Hospital During COVID-19

This study aimed to understand the levels of compassion satisfaction, burnout, and secondary traumatic stress in clinical nurses in a small community hospital. Additionally, the study evaluated evidence for significant differences in compassion satisfaction, burnout, and secondary traumatic stress based on demographics including age, years of experience, and unit worked. And finally, the association between lower levels of compassion satisfaction, greater levels of burnout, and greater levels of secondary traumatic stress and working in a COVID unit versus working in a non-COVID unit was evaluated. Led by principal investigator, Peggy Rupp Wysong, MSN, RN, CNS, CCRN-K, the study was conducted in May and June 2021.

Survey method:

Surveys were sent to Goshen Hospital direct care RNs in the Emergency Department and all Inpatient Units (ICU, PCU, 4W, 4E, Oncology, Birthplace, CRU). Professional Quality of Life (ProQOL)-Version 5 was used to measures 3 distinct subscales: Compassion Satisfaction, Burnout, and Secondary Traumatic Stress (STS).

Survey results:

Survey was sent to 177 nurses with 119 completed the survey with a 67% response rate.

Compassion satisfaction

Goshen Nurses’ Score: Moderate
Optimal score: High

Burnout

Goshen Nurses’ Score: Moderate
Optimal score: Low

Secondary traumatic stress

Goshen Nurses’ Score: Moderate
Optimal score: Low

Significant differences based on demographics:

Female scores were significantly higher (worse) for Secondary Traumatic Stress, than males
RNs working <24 hours/week during COVID had significantly lower (better) scores for burnout than RNs working any other category (25-36, 37-40, 41+)
ICU had significantly higher (worse) scores for Secondary Traumatic Stress than non-COVID units
Average score for RNs and all units’ individual scores were in the moderate range (sub-optimal, but not in the worst category) for all 3 subscales and met criteria for moderate compassion satisfaction, burnout, and secondary traumatic stress

Discussion and interpretation of results:

It may be reasonable to surmise that the challenging work environment has impacted every unit at the hospital, as we see sub-optimal levels in all 3 subscales. Issues such as difficulty staffing, nurses working extra hours, and the disruptions caused by the COVID-19 pandemic impacted nurses throughout the hospital.

This study shows that nurses on all units studied have suboptimal levels of burnout and STS, and data from previous studies show that burnout and secondary traumatic stress affect not only nurses, but also have negative implications for patient satisfaction as well as patient outcomes.

Also, since nurses from both the COVID and non-COVID units demonstrated sub-optimal scores, efforts toward resiliency and healthy work environments are needed for all nursing Colleagues. This has been a focus of our hospital, with numerous well-being initiatives implemented.

Planning for the New Patient Tower

Leading up to the opening of the new patient tower, nurses were instrumental in the design and planning for patient rooms, equipment, and technology. Leaders created many opportunities for nurses to provide feedback in the decision-making process. Nurses voted on their favorite patient room furniture after seeing and testing multiple options in a ‘furniture showcase’ set up in a hospital conference room, provided feedback on new beds after off-site vendor presentations, and gave input into the new nurse call system. Consistent with The Uncommon Leader (TUL) philosophy, clinical nurses, as the end users closest to the work, were instrumental in the planning for and adoption of the new technology and equipment.