A Day in the Life: Covid Edition

by Anne Summach, NP

One thing that has been clear over the past 10 months, Alberta’s healthcare system is under greater pressure than every before. The COVID-19 pandemic arrived on a foundation of healthcare worker unrest, pending retirements, and threats of physician exodus from the province.

Out of the ashes, Nurse Practitioners have risen to fill many gaps throughout the system. They have been tasked with increased responsibilities and authority in areas which had previously been limited by legislation or history. Our blog this month attempts to describe, from the point of view of NPs working throughout the system, what effect COVID-19 has had on healthcare, frontline clinicians, work relationships and collegiality, and in our homes and communities. We had the opportunity to interview three nurses practicing in supportive living, community and hospital settings. Each question posed will have snippets of answers from each NP, creating a mosaic of our COVID experiences.

Here are our featured NPs this month:

Describe your position as an NP, what your role has been, and how your role fits in with your practice organization.

In Primary Care, Brittany works as part of a team at the Good Samaritan Seniors Clinic providing primary and consultative care for clinic and homebound medically complex older adults and people with dementia. The interprofessional team also consists of physicians, nurses, social work, exercise specialists, respiratory therapists, dietitians, pharmacists and administrative staff. “I’m one of two NPs at the clinic and had been working for only 3 months as a Graduate Nurse Practitioner when the pandemic started, with the other NP returning from maternity leave in September.” 

Haley reports that her role involves “providing timely access to medical care for clients living in Supportive Living, as well as to provide staff access to an advanced practice nurse to assist in problem solving client care”. Even though her job is primarily consult based, she also takes on the role of Primary Care Provider for most of the clients in her small site. 

Lesley has been working in the RAH ICU since 2012, though has been practicing in other areas since 2009 as an NP. Their ICU cares for tertiary medical, surgical or trauma patients. She provides tier one clinical care to adult critically ill patients. She rounds independently in ICU, responds to codes and emergencies, supervises residents, completes procedures and helps to provide 24/7 coverage to the unit.

What about your role or your day-to-day experience has changed since the pandemic took hold?

Because of the risks of transmission within precarious supportive living or LTC sites, Haley found that her ability to work across sites was significantly curtailed. Two of the sites within her responsibility, both LTC centres, struggled during COVID-19 outbreaks to provide sufficient professional nursing care as infection numbers rose and staff required isolation. She comments that “I think COVID has really made all care providers become more flexible in how they provide care, and where that care might be provided”. This is echoed by Brittany, who reports “I’ve taken on more non-clinical roles since the pandemic started. Not only am I doing home visits, ordering labs and investigations, following up hospital discharges, but also writing process so the clinic can safely operate and continue to support our 1300 clients in Edmonton”. 

Lesley is experiencing an ICU no longer operating within its 25 patient capacity, but now swelled to 40 patients, most with severe COVID-19 pneumonia. They have had to add a third team of clinicians to manage. This means that Lesley is adding additional shifts to ensure the team has NP coverage. A steady flow of admissions, in the midst of managing multiple critically ill patients has been a “tremendous cognitive load. The surge has extended our boundaries outside of the ICU into the recovery room area, adding the extra challenge of managing critically ill patients in different geographical locations”. 

It is clear that the pandemic has pushed NPs to expand fully into all aspects of their practice, including leadership of inter professional targeted teams, education of those teams regarding infection prevention and control, and front line data collection and research into the best manner to approach an unknown and aggressive pathogen.

Brittany also comments on the increased role of personal protective equipment (PPE) in practice. “There is less in person interaction and when issues can be managed over the phone or video visit I try to do that, but a lot of the time that’s not possible. So I am still going on home visits but now navigating donning PPE in my car or outside someone’s house in Edmonton winters.”

Describe one significant thing you learned about the NP role within your current practice environment, particularly since the beginning of the COVID-19 pandemic.

What has been made brilliantly clear throughout 2020, how appropriate given it was declared The Year of the Nurse & the Midwife, is the incredible value that nurses of all stripes bring to Canada’s healthcare system. Haley describes exactly this: “My experience of going into long term care sites really emphasized to me how the role of the NP can enhance care of persons living in continuing care. The role has been so well integrated into the Supportive Living sites that I work in that it was really apparent to me how long term care could also benefit from having access to both the nursing and medical care expertise provided in the NP role.” This must also have been obvious to the Alberta Government this year, as they took unprecedented steps to remove legislative barriers to NP practice. Changes to the Nursing Home Act have legitimized NP practice in long term care, allowing NPs to work to their full scope. We can only await the advent of the new Continuing Care Act which is in development – hoping it will further clarify the capacity of NPs for all Albertans in care.

Brittany highlighted the flexibility and nimbleness of NPs – in spite of being sources of stability in their practice areas, their role has the adaptability for changing site needs and acuity, a fact that “has been even more evident with the pandemic”.  Lesley highlights “the multifaceted skill level and knowledge of our NP team”. The team provides incredibly diverse and technical care with active participation in the multidisciplinary team. “Our particular skill and ability have positioned nurse practitioners to pivot and provide quality critical care for patients in a variety of ways, augmenting the care provided by the intensivists and the multidisciplinary team.”

Describe the challenges you face in your position, focusing on how the outbreak has changed your role over the past 10 months.

Brittany entered the pandemic as a GNP, and had no NP colleague for the first 6 months of the pandemic. “Being a new grad, in a new role, without another NP for the first 6 months was particularly challenging for me. I felt alone and unsure.” Haley commented on the challenge of “trying to provide ‘distance’ care to clients who I would normally have been able to go and assess on the same day.” As clients become more complex, providing care within COVID-19 limitations becomes more difficult. “The reduction in services and resources has made it increasingly difficult to keep people out of hospital and support chronic disease in the community”.

If we feel the stress of life during a pandemic as healthcare providers, the effect of pandemic restrictions on frail seniors or those with complex health conditions can be much more significant. “It’s…been challenging to see the cognitive, functional, and emotional impact of the pandemic on our clients. I think this pandemic has really highlighted the value and importance of social connection on all aspects of health” states Brittany. Haley has experienced the same – “reassuring family members who have had their access to their loved ones in care reduced from what it would normally be…it was always a challenge to be calling families about clients who are declining and trying to understand what their wishes would be in regards to goals of care and ensuring that we are also respecting the client’s wishes as well. Especially since these are families that have not previously spoken to me, and you need to develop a trusting relationship in the midst of a very difficult conversation”. From Lesley – “the greatest challenge has been the emotional toll of bearing witness to the journey of COVID-19 patients. Listening to patients have their last conversations with families before being intubated, knowing that these may be their last words is heartbreaking…There are shifts where you are busy trying to stabilize a patient who rapidly succumbs to COVID-19 and have to call family with tragic news.”

And, Lesley emphasizes, antimask rhetoric or denial of the pandemic in the community or on social media while you are immersed in the pandemic tragedy can feel like a personal attack, exacting an incredible emotional toll on health care workers.

What personal rewards have you experienced as you provide care during this pandemic?

Our NPs had some common themes: robust opportunity to practice to full scope, a chance to demonstrate the leadership capacity of NPs in a time of challenge, the value of inter professional team work, and the cohesiveness of a healthcare team dedicated to mutual goals – the health of our clients and patients. Haley mentions, “all the care teams I work with just seem to be so much more cohesive than before and helping to pick up the slack for each other when there are limitations in staffing”. Lesley also reports: “I work with an incredible team of healthcare providers including nurses, respiratory therapists, physicians, managers, clerical support and allied health staff. The support that our team provides each other…has been inspiring.”  It really does “take a village”, and our NPs are working in villages across the healthcare system, strengthening their connections with other disciplines.

Lesley also describes the gratification of transferring survivors of COVID-19 out of the ICU and back to their lives. “Mid-January we discharged a severe COVID-19 survivor who had been on our unit since November and our staff gave her a round of applause as she left – this was a positive moment on this pandemic rollercoaster”. Brittany finds “it fulfilling to play a supportive and therapeutic role for people in the community, and I’ve had a chance to really embrace that part of my role”. 

What aspects of the NP response to COVID do you think should be highlighted to the public?

A unanimous reponse – LOOK AT ALL WE CAN DO! “The NP COVID response looks different across roles but each NP is playing a critical role.” “The ability of NPs to provide care in all streams of continuing care”. It is clear that we are not only front line clinicians, but influencers and educators within the system. “Our advanced nursing skills also help to provide support to the [other] nursing staff to improve client care”. Lesley reminds us that “nurse practitioners have had a multi-faceted role in caring for COVID-19 patients. We have a unique role comprised of direct clinical care, recognition of COVID-19 complications, managing mechanical ventilation…initial rehab of survivors, participating in pandemic response strategies…and bearing witness to the emotional toll this has had on patients, families and staff. It is a truly unique role and perspective”.

As NPs move into a new phase of practice in Alberta, it’s important to showcase our work. Highlighting the work that is happening right now “gives light to what would be absent without NPs”.

What role should the NPAA be playing to support you and Alberta NPs during this incredibly challenging time?

As the NPAA adapts its mandate and approach, we have been told that there some key priorities:

• “Keep pressing that NPs provide [valuable and timely] medical care to clients within a nursing lens…There is a real need for NPs in…continuing care. I feel the NPAA could play a large role in helping to forward that agenda”.
• “Being a small profession in Alberta right now can be especially isolating. [The NPAA can] provide a community for NPs across the province to be able to connect and to highlight the variety of work that NPs are doing”.
• “Continue to advocate for our role at provincial and [organizational/employer] levels, as we may be facing a tumultuous time in health care with possible future re-structuring.”

Editor’s Note: The Board at the NPAA is so incredibly proud of the work that all NPs are doing across Alberta, and the country. It has been a difficult time, certainly. And yet, in challenge, the value of this role and these people has been highlighted to the system, and to the people of Alberta. Never have I been more honored to serve alongside all of you.

Please consider joining our telephone town hall on January 26th at 6:30 pm. If you have not received an invitation, please email secretary@albertanps.com.