Throughout the course of this year, communities across the world have had to pause and reflect on how life will change in the context of a rapidly growing pandemic. The novel coronavirus disease or COVID-19 has put in question the safety surrounding all aspects of society, ranging from large-scale public services such as local transit systems and health services to how citizens shop for groceries. As COVID-19 continues to be a reality in the lives of many, one group of individuals stand out in their commitment to protecting and providing care to those around them in the face of adversity: frontline healthcare workers. Frontline workers can be found across all branches of healthcare delivery, spanning numerous professions and walks of life, but are ultimately tied in their duties to the communities in which they serve as links between health systems and the people. As a way to connect with those frontline healthcare workers in our local Toronto community, the University of Toronto Chapter of the Institute of Healthcare Improvement (UTIHI) reached out to a registered nurse, police inspector, obstetrician gynecologist, and community pharmacist. The conversations that ensued shone light onto both the professional and personal challenges of navigating an ever-changing healthcare delivery and policy landscape as well as the unintended consequences of the decisions made in an effort to manage these unprecedented times. Below are excerpts from these discussions. The frontline healthcare workers included here have requested UTIHI to keep their names anonymous. We at UTIHI are thankful for the continuous efforts of all frontline healthcare workers across Canada.
UTIHI: How has your role changed throughout the course of COVID-19 and in what ways, if any, do you predict it to change moving forward? Registered Nurse (RN): The pandemic changed many things at the hospital I work at, and these impacts were seen in all areas including the emergency room and inpatient rooms. We were forced to alter the way care was provided, including a major shift from team-based care models to individual nursing care for patients, in order to minimize contact and overlap. This was challenging as I found team-based care allowed for more collaboration, interpersonal support, and task management. During this time nurses were also separated into those who stayed with patients and provided care and “runners” who stayed at the centralized nursing station and spent their shift bringing supplies and medication to those with patient assignments. Those who were in direct contact with patients were now considered “dirty” nurses and runners were known as “clean nurses”. During this time, the dirty and clean nurses were instructed to use separate break rooms and bathrooms and a stigma was created against those who were “dirty”. Overall these polices were essential to help stop the spread of COVID-19, but unfortunately, I think they also negatively impacted the nursing staff and patient care. In the future, I believe this individual style nursing might stay in order to minimize exposure to different pathogens, but hopefully new ways of team collaboration will be created so we do no lose the benefits of team styled care. Police Inspector (PI): I am in charge of a busy police station in Toronto with over 250 officers. Since COVID-19, our station has been closed to the public. I have not had any face-to-face meetings with members of the public or other community groups since about mid-March. We have had to find different ways to connect with members of our community and address their concerns. In addition, my officers have greatly reduced their interactions with members of our community. Obstetrician Gynecologist (OBGYN): I have been taking additional precautions in the office setting, such as plexiglass dividers at the front desk, no waiting room or visitors permitted, and increased sanitation. We have also begun converting possible consults to tele-based medicine. The biggest changes have been the drastic changes at the hospital with what we are permitted to do. All general gynaecology services have been completely on hold including pre-malignant conditions such as colposcopy as well as significant menstrual disorders of women requiring surgery for benign or early gynaecological cancers and/or adnexal masses. I am unsure what this will mean for my patients when care resumes; I predict we will be behind in the operating room for quite some time. Community Pharmacist (CP): My role hasn't really changed. I still provide medication to patients and education regarding their medications as well as help with minor ailments. With the protective barriers, I do not have the same physical contact with patients as before. As well, we are not providing sit down consultations or going to patient's homes to discuss medication management at this time. However, my workload has increased. Patients are afraid to go to the ER when needed and some people have become very seriously ill because of this. Patients come to us first, either calling us on the phone or coming into the store. Due to virtual care, many medical practitioners call to speak to us as they are working from home and do not have access to patient files or fax machines which adds more and more to our stressful days. Minor ailment prescribing will be in our future as well as providing more testing and vaccines. Thus, our workload will only increase more.
“Patients are afraid to go to the ER when needed and some people have become very seriously ill because of this. — Community Pharmacist
UTIHI: What has been the greatest challenge for you thus far in facing COVID-19? Have there been any positives that you have seen come from these efforts? RN: I think that the greatest challenge facing nurses during this pandemic is receiving adequate support. The most obvious challenge being the supply of personal protective equipment (PPE). Supplies of PPE especially at the beginning of the pandemic were very limited. N95 masks were and still are under lock and key and nurses are only allowed to use them in aerosolizing procedures. Even though the research is inconclusive, N95 masks were denied to nurses unless they were providing CPR or in an aerosolizing generating procedure. In addition, at the beginning of the pandemic there were not enough gowns or face shields, so nurses were forced to clean them with sanitizing wipes between patient rooms.
Another issue was the fact that even if exposed to a COVID positive patient without the proper PPE, a nurse could not get COVID tested without being symptomatic. This made it very scary to work in any department other than the COVID positive unit because you could be exposed to a positive patient without even knowing it and without taking the proper precautions and you would not be able to be tested after. This put nurses and their loved ones at a greater risk.
On a positive note, the support from the community was incredible. Family and businesses were sending food, gifts and kind words to the hospital daily PI: It has been very challenging managing manpower resources in the COVID-19 environment. Ensuring adequate PPE for officers and limiting exposure. Officers going into hospitals with apprehensions and arrests are at risk. Further, many prisoners who come into our stations are symptomatic. This daily exposure has often led to having to quarantine officers for 14 days which impacts our ability to properly staff our station. Officers have become more conscious about cleanliness in the station which is a good thing. OBGYN: By far, the greatest challenge has been the policies and procedures regarding healthcare and patient safety, which have been completely dictated by available PPE. What was previously an unacceptable level of protection has now become appallingly “good enough”. Positives have included employee willingness for redeployment. It is also a positive feeling to know that healthcare workers, even in the face of inadequate PPE, continue to make patient care of utmost importance.
“What was previously an unacceptable level of protection has now become appallingly “good enough”. — OBGYN
CP: The greatest challenge is the increase in workload. At my current practice, a typical day was about 200 prescriptions in my shift. Now it is 400 with the same number of staff. This has mainly occurred from the quantity restrictions, billing issues, the government then paying the fee and now back to 90 days. As well, due to supply shortages of medications, it takes more time to find a substitute or to find stock.
On the positive side, a lot of people have expressed gratitude and thanked us from day 1. This has meant a lot that some people really appreciate that we are open, accessible, and doing our duty to keep them safe and healthy. The government has added a lot more to our workload with the 30 days restrictions, then paying the co pay, and now reverting back to the 90 day.
Note: At the start of the pandemic, Ontario placed a 30-day limit on prescription medication to prevent potential supply shortages. This restriction was lifted on July 1, 2020 and the regular 90-day maximum was reinstated. UTIHI: Do you have any words of encouragement or support towards those who are currently starting to pursue careers as frontline healthcare workers? RN: As a new nurse, it was overwhelming to face a pandemic within the first year of working but everything is manageable if it is taken one day at a time. Find strength in the positive impact that you are able to make in people’s lives. 2020 has shown us all that there are countless bad things in this world that nobody can control but nursing allows you to take control of a bad situation and make it better. Not everyone gets the opportunity to impact people’s lives like first responders, so even in the most stressful times those who are truly passionate about what they do will continue to push forward and so should you. You never know what you are really capable of until you are challenged.
“Not everyone gets the opportunity to impact people’s lives like first responders, so even in the most stressful times those who are truly passionate about what they do will continue to push forward and so should you. — Registered Nurse
PI: Working in policing is a rewarding and meaningful career. Times of crisis, such as this, allow us to see how serving the public can be rewarding and challenging at the same time. OBGYN: Experiences like medical pandemics are extremely challenging to navigate. Information changes minute by minute. It is helpful to know that we can work together in these challenging times to try and arrive at the best solutions to problems and hopefully accumulate data in the event that this should occur in future pandemics. CP: When most people decide to become a healthcare worker, they understand that they have a duty to help others, above themselves. As long as the work environment is safe and you can do your job to your best ability, you should be proud of the work you do to help others. Although my workload and stress has increased tremendously, I try to stay positive knowing that what I do is important and that it makes a difference in people's lives. UTIHI: We would like to thank you for your incredible diligence and commitment to your field and contributions to society. Our chapter appreciates the complexity involved in navigating the COVID-19 pandemic. At this time, we would like to ask you if there is anything else you would like to address, voice, or raise awareness on? RN: It would be interesting to look at the fear of hospitals that now exists. Many people who are sick and require medical attention are avoiding the hospitals –- or have avoided them for the last several months – and are now in a much more critical condition. PI: Nothing further, thank you. OBGYN: I think healthcare workers should be applauded for their charitable and philanthropic works. Many have tried to raise funds for PPE etc. This goes beyond the call of duty and further illustrates their commitment to health care and their profession. These selfless acts are done purely as acts of kindness. There is no career advancement or any personal gain to be had. CP: Nothing else, thank you.
Overall, several themes have come to be shaped throughout these conversations. First and foremost is the selfless bravery and generosity frontline healthcare workers have shown both professionally and personally throughout this time. Their dedication to public health, patient care, and to strengthening our communities more broadly have been on display every day during this pandemic and deserves to be applauded. Another theme is that of the impacts of ambiguity and mixed support on the efforts to curb the spread of COVID-19. The fear and uncertainty regularly felt by frontline workers brought on by a lack of information and insufficient PPE stocks was deeply concerning with respect to both the potential mental health implications these environments can have on workers as well as the restrictions on quality of care and service they are able to provide. Furthering this point was the stigma placed on those who were in direct contact with COVID-19 positive patients by their peers and, at times, the greater community. This exemplifies the potential for unintended consequences with any single solution and the need to be aware of the weaknesses of alternatives in order to execute strategies that adequately minimize these unwanted outcomes. A silver lining to this experience is the overwhelming support shown by communities towards their frontline workers. Supporting one another during times of uncertainty is vital for the strength of a society and in overcoming the challenges ahead. Ultimately, we would like to encourage readers to continue their support for the work frontline workers are engaged in on a daily basis as we move onto the next stages of this crisis.