Covid Story 9

Photo by William McCue on Unsplash

Tracey Jones, The University of Manchester, UK

How Covid 19 has affected education provision: A senior lecturer’s reflection: The consequences of the Covid 19 pandemic has been felt far and wide. Never before have we experienced the impact of such a global crisis reaching all areas of the world. In the United Kingdom the impact of isolation and being quarantined to our homes has resulted in many of

us adjusting the way we socialise, communicate and work. Whilst our front-line healthcare teams continue with their work and deal with the health crisis, as an educator my support for these teams has been in a different way. As a nurse educator my key area of work is related to educating undergraduate nursing and midwifery students and leading on continual professional courses related to neonatal care. The government guidance to cease face to face contact led to all teaching being changed to online learning. Almost overnight we had to leave our offices, set up online teaching, rearrange face to face exams and find new ways of working. As an academic team we were forced to explore how and if we could continue to run the CPD courses and if so, how could we support the students to reach their end goal of success and academic accreditation.

Some would argue that this crisis has offered an opportunity to revaluate education provision. Year on year course evaluations demonstrate that students specifically CPD students enjoy face to face teaching. One would argue that the discussion that transpires when a room of neonatal nurses from a range of organisations come together is priceless, encouraging shared learning, initiating questioning and prompting change in practice. So how do we continue to nurture this environment whilst working at a distance? For me as an educator zoom has been a lifeline offering me the opportunity to hold meetings, assess neonatal intensive care Viva’s and continue to encourage student joint engagement.

There is no doubt that the Covid 19 crisis will continue for some time demonstrating that not only have we had to evolve but also plan for future education provision. Healthcare teams will continue to require CPD education courses and the neonatal workforce must still aim for 70% of the nursing establishment to be ‘qualified in specialty’ [UK Dept. of Health, 2009]. It is important now to analyse how we as educators can support clinical teams to achieve this. The future requires all those working in education institutions to seek new ways of offering distance learning that keeps the students engaged, motivated and ensures that CPD education equips healthcare teams with the knowledge they require to offer both safe care and drive change.

Covid Story 8

Photo by Philipp Baumann on Unsplash

When PPE stands for Preventing Portrayal of Emotions

Due to the necessity of wearing personal protective equipment as routine uniform during the COVID pandemic, the only visual aspect of our identity that parents see is our name badge. Although our eyes are visible, the physical barrier of visors, goggles and masks create an obstruction for parents of preterm infants to see our emotions, empathy and feelings. It is our ability to interpret, display and respond to emotions that cements our nursing practice. Our caring hands can no longer extend for greetings or be placed on shoulders to deliver a gentle touch to inform those that we are here and we understand. Our non-verbal communication has been diminished when we obstruct our mouths, faces and reduce touch to convey emotion or connection. The connection and touch is what parents remember from the point of admission and throughout the roller-coaster journey in the neonatal world. The hustle and bustle of the gowns and aprons are drowning out the monitors and natural neonatal sounds that we have learnt to live with and use as our daily backing track. As the ambient environment maintains it’s neonatal tune, new PPE measures are impacting on our verbal communication with reduced audible clatters as voices are muffled and hushed by the 3 play masks or restricted by the sealed ventilation device on the enhanced airway protection. We are discovering our reliance on lip reading is evident more now than we assumed we had. When the most common phrase in the units was “does anyone have the keys”, this has been replaced with frustrated tones of “can you repeat that please”. As we draw in air to repeat the request our breath reminds us how times have changed and how a return to normality seems unlikely within our generation. Just as the nursing hat and waist bands were once the pinnacle of nurses uniform, this generation will have face mask fittings before sizing up for uniforms- the focus will be on protection of ourselves rather than caring for others. While this vision seems to be our direction- the art of nursing will change along with the times and nurses will continue to care for patients while leading through the power of prevention and education. We need to hone our skills when communication is hindered to ensure we develop better skills to communicate with each other and those in our care. As we understand the changes ahead and how to map out the neonatal pathway through COVID-19, we need to ensure that as a community of neonatal nurses and midwives that we do not let the impact impair our ability to care or portray that emotion to parents when they may feel alone and scared at a vulnerable stage of their parenthood.  We need to ensure that COVID-19 has the smallest impact on neonatal care.

Covid Story 7

Photo by Patrick Pellegrini on Unsplash

Laura Moore, Registered Nurse
Neonatal Intensive Care Unit, Starship Children’s Health, Auckland, New Zealand

COVID19 has meant a complete shift in how I work. As a neonatal nurse usually at the bedside (or incubator side!) I’ve found myself wandering through adult and paediatric wards, answering calls from nurses, doctors, cleaners, security and administration staff. From tiny babies one week, to helping security men double my size safely don and doff their PPE the next, it has truly been a lesson in flexibility.

Our neonatal unit created a “COVID Team”, swiftly followed by a To-Do list that seemed to grow each day. One of our first priorities was screening parents. We took a multi-layered approach, screening at least 3 times from outside the unit to the bedside. In addition we created a station at the entrance which gave parents the opportunity to clean their phones and wash their hands, and set up a register for parents to facilitate potential future contact tracing.

We designed guidelines for admissions and deliveries with associated care plans, and edited them, and edited them, and edited them again with each new piece of Ministry of Health guidance.  We cleared out rooms for isolation, printed educational posters and laminated everything. We put out weekly FAQs, to provide constant and consistent feedback to staff and to ensure concerns were responded to promptly.

In conjunction with the New Zealand government’s alert levels, the neonatal unit altered to reflect the same. Visitation was reduced to exclusively parents with only one parent at the bedside per visit. We reduced the number of people who could be in shared spaces such as the mother’s room, work room and staff tearoom at any given time to facilitate social distancing. We increased our use of teleconferencing apps which facilitated reducing the number of staff on ward rounds, meetings and education sessions. We took every opportunity we could think of to try to reduce contact and therefore reduce risk.

This was a collective “we”; however I found myself inadvertently becoming a person staff felt comfortable raising their concerns and anxieties to as COVID evolved, both in formal and informal conversations.  My nursing colleagues began to contact me increasingly over social media, sharing concerns and questions that they perhaps did not want to raise directly at work. I was moved that people felt comfortable to give their honest feedback and ask me their questions, even if I didn’t have all the answers myself!

The world suddenly feels uncertain; healthcare workers are only human and have a life and worries both inside and outside the hospital walls. Managing staff anxieties, ensuring their concerns were heard, and hopefully helping them feel protected and valued has been, in my opinion, the greatest achievement of our “COVID Team”.

Working as part of the team of the greater hospital has underscored how this is new territory for us all and we need to venture into it together with kindness, compassion and a degree of flexibility. I feel hopeful that by retaining our humanity through a collective effort and empathy with one another and our colleagues across the globe we can protect our tiny precious patients, their families and each other.

Covid Story 6

Photo by Raphael Andres on Unsplash

Nicole Gustafsson Valderrama, New Karolinska University Hospital, Stockholm, Sweden

Since the beginning of Covid-19 the routines about how to approach the parents if they are positive and/or have any related symptoms has changed a lot. Sometimes It feels like we have new routines each and every week which builds up a frustration because there is not always time to learn the new routines. But we all try our best. For the most part, life at the NICU continues a lot like it did before Covid-19. Parents are still encouraged to be with their children as much as possible and be a part of the daily routines that we have (rounds, diaper change etc.). That is if the parents have NOT tested positive or to have shown any symptoms correlating with Covid-19. Other visitors such as grandparents or siblings are not allowed at the ward (nor in the hospital).

About kangaroo care there are no restrictions as long as the parent is tested negative. Today the routine is that if the parent was to be tested positive but does not showcase any symptoms they can still take care of the child but not to kiss or perform kangaroo care, and the health care staff needs to use face shields when caring for the child with the parents. The child is never seen as infected unless a test is done and comes back positive. We only screen the children if they need surgery (before) or if we have a child that comes from another hospital. This has created a bit of insecurities amongst the staff because we feel that we are not given the chance to fully protect ourselves and also what guarantees us that the parent does not have an active infection and just don’t have any symptoms? Or just in an early stage of the infection? Where should we draw the line between what is ethical for the children and their families and our safety? Since we work with the idea of a family centered care it is normal for us that the parents are a part of the daily routine, but now they can travel from their homes to the hospital, be accompanied with whomever they choose (because we don’t have any restrictions in Sweden, only recommendations) and then coming back to the hospital to be taking care of the children with us standing only centimetres apart from them. So, there are some concerns on how to approach this situation properly since we want to continue the family centered care but still have our health as a priority as well as not risking bringing home the infection to our loved ones. 

I have been distancing myself from everyone except my closest family whom I live with because I don’t want to spread the infection to others nor be infected.  If I am sick it will affect the whole unit because we already have a lot of staff that are sick (not necessarily in Covid-19). We try to make ends meet but it is taking a toll on our mental health because a lot of Swedish people don’t understand the severity of this infection. We are next to a ward where the sickest people that have been infected are getting treated and we can see the staff with all the protective gear whilst the infected sick people just lay there with all the machines surrounding them. It is scary and it makes me mad that a lot of Swedish people just go along with their lives as if nothing is happening, especially a lot of people my age (I’m 24 y/o) because they don’t believe they can get infected. But we can all get infected and it is my fellow colleagues who work at the frontline that get affected the most. And when they

can’t take it anymore it will probably be our turn to go to the adult units and treat the Covid-19 patients. It takes a toll on my mental health not knowing if I will get my vacation this summer because I want to spend time with my family as well, but I don’t because I need to put the safety of my small patients, my colleagues and the society before my own needs. And we all need to think like that so that we can see the light at the end of the tunnel and hug our loved ones.

Covid Story 5

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Joana Mendes, São Francisco Xavier Hospital, Lisbon, Portugal

I am a NICU nurse since I left nursing school. It was my big and only passion. I work now for about 18 years with babies and families. My main areas of expertise are ethics and palliative care. When Covid-19 was spreading quickly in Europe, I was doing a pediatric palliative care clinical practice in Cardiff. One of the first challenges, was returned home safely, when boarders where closing, all over the world. I got to Portugal 2 days just before the lockdown. The news, papers and social posts on internet, arriving from China, Italy and Spain, were really scary. Portuguese boards (medical, nursing and even veterinary’s) asked for health care professionals, from all backgrounds and scenarios, to come and help in human medicine, especially in adult emergency department and intensive care, if needed. They even asked the retired ones to volunteer. And they came. Neonatal nurses knew in advance, one could be mobilized anywhere, anytime. If the situation turned really bad, some would have to go and work in adult department. It sounded very unreal. Some of us when to the pediatric emergency department, when a lot of nurses were home due to quarantine needs.  How would we help in adults? The second challenge faced, was the decision to left my sons (2- and 7-years old) with my husband and fathers in law. I felt heartbroken with all the uncertainty. I experienced strong and mixed feelings. Like never before, I listened the silence shouting and felt time passing in a very painful slow-motion way.  In the hospital I work, one building was converted in a Covid-19 area. The other, the maternity, neonatal and pediatric building, was considered the non-Covid-19. NICU would admit babies that where born from mothers that tested positive or babies, during neonatal period, suspected to be or tested positive. Since, labor and delivery unit started testing all women, some, with no symptoms or risk factors, tested positive. Evidence was lacking, but the risk of vertical transmission seemed to be low (hopefully).

Neonatal health care team were daily, adapting, adjusting and reframing institutional guidelines. Would using CPAP would increase the risk for professionals’ transmission as suggested in adult literature? Was it possible to do the test properly to smaller babies, if the swab used is the same size in adults and newborns? Planning was very dynamic and all we were learning from one another, around the globe.

When the time came, NICU nurses, that had previous working experience in adult ICU and had with no risk factors for Covid-19, went to work full time there. NICU also admitted a nurse from ICU that had a chronic condition. The others non-risk nurses, like me, would be the first to take care of Covid-19 babies. First admissions came in Easter time. NICU nurses were committed to promote mother-baby bonding, holding concept and family centered care. Even before the first baby was born, were all brainstorming. A mobile phone or a tablet was identified as a good option to send video, photo or promote face time with the mother, if possible. Nurses phone called mother’s, each shift, to update about baby’s situation, lactation advices and other areas of counselling and promote emotional support.

Full protection equipment use was hard. No possibility to eat, drink or use toilets to optimize the deficiency in the number of equipment’s available. Even for a couple of hours, makes you feel hot, dehydrated, sometimes dizzy, with fogged glasses and with a sort of shortness of breath. After you remove it bruises and pressure zones in your face can remains for hours or days. All babies that were born during this pandemic time, not only Covid-19, suffered touch and human face interaction deprivation. Parents stayed in the NICU for short periods of time, because they were afraid. Professional were all wearing masks and gloves. The

noxious sensory hyper stimulation seemed to gain preponderance to Kangaroo care, holding or breastfeeding. Difficult balance: health safety or human healthy development? What will be the consequences of this new crazy reality for next generation? What lessons do we have to learn, in order to elevate the quality of nursing care in the near future? This would be, the huge, third challenge. It was really inspired to feel that neonatal and pediatric palliative care were supporting one another in the globe. I felt we were really as one, sharing emotions and difficulties and being inspired to move forward.

Covid Story 4

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Harriet Vickers, Neonatal Unit, Rosie Hospital, Cambridge UK

I arrived for my night shift and as usual entered the unit through our reception, only to find a huge sign in place explaining how guidance from hospital chiefs stated that parents are no longer allowed on the unit. As parents are usually allowed unlimited access to the unit and their baby, this was a shock for the unit and all families. This decision was only in place for 24 hours but the impact on families was huge. Our visiting times then changed to one parent per baby for a maximum of 2 hours a day and each parent had to come at a separate time to the other parents visiting their babies. Our work as neonatal nurses had changed. As we usually care and support parents almost as much as their babies when they visit, to go to only seeing one for 2 hours a day was vastly different. It was heart breaking picking up the phone to update a parent on their baby’s condition and hearing them breakdown with anxiety as they had not been able to see their baby for days. This taught me to aim my care towards empowering parents when they do visit and to make the most of the new Face time options the senior staff set up on the unit. To use the 2 hours to help that mum to breast feed for the first time, first skin to skin with dad and to really get each parent involved as much as was appropriate with their baby’s care was more important than ever.

Parents are still part of the baby’s care team and thus should be treated as such even under the new conditions that are in place for everyone’s safety. Something we all must try and hold on to during this uncertain time to ensure we still provide the excellent care we love being a part of.

Covid Story 1

Barbara Howard, The University of Sheffield, UK

COVID-19 has certainly been a force for change in neonatal academia. Like a typhoon it has spun through our relatively ordered world, thrown everything in the air and left students and academics trying to guess where things will settle when this is all over. On the negative side I have seen the impact upon students working clinically, both emotionally and physically. The effects of these stresses vary across individuals but affect all to some degree. I have seen carefully planned teaching sessions and assessments collapse at a moment’s notice, affecting students, teachers and the clinical areas desperate for more qualified in speciality neonatal nurses. The sense of loss is unsettling and profound. But there is a flip side to this; I have seen the best of my students as they have stepped up to the challenges in a professional and caring manner which makes me proud of them and of our profession. University colleagues and myself have been on an incredibly steep learning curve as the university moves online to deliver teaching, tutorials and academic assessments; COVID-19 has driven very rapid changes in higher education which I believe could be of real benefit to future neonatal nursing students. These different ways of learning could benefit part-time and distance students and offer flexibility in studying appreciated by those juggling the demands of family life and full-time employment. We should never underestimate the threat of COVID-19. We should never forget the sacrifices made and the lives of loved ones lost, but from this threat comes opportunity for change in neonatal nursing education and the chance to make it better than before. As neonatal nurses we should reflect on this, then lead forward together. 

Covid Story 2

BRITTANY KYLE

Neonatal Intensive Care Unit, IU Health Ball Memorial Hospital, USA

Written in March 2020: I am a NICU nurse and, as such, I am not on the front lines of this pandemic (yet). There is a lot of acknowledgement for healthcare workers, especially nurses, and I feel guilty for not being on the front lines. I feel guilt, and relief, and then even more guilt for feeling relief. But I also feel fear. It is always present, always looming. There is not much data on how this virus affects newborns and the virus is constantly evolving. It feels inevitable that we will be faced with it on our unit and in our population. I fear that first patient. I fear we won’t know how to help them. I fear we might not even recognize it before it’s too late. I fear what this might mean for our most vulnerable patients – the patients born so early and so frail, with no immune system to speak of and already fighting the greatest battle of their lives. I also fear the added trauma my patients will experience by having their earliest days, weeks, and months of life with caregivers whose faces are half covered. I fear what not having the experience of seeing facial expressions of human emotions will do to their development. I fear that they will feel and embody the pervasive anxiety that is felt by every healthcare worker. Stay home. Stop the spread. The babies I take care of fight so hard every day. Do your part in keeping them from having to fight even harder.


Figure 2: Source: Brittany Kyle, with permission

Written later in May 2020: As a NICU nurse in the pandemic, I continue to worry for my patients. I feel less fear, but I still have concerns. The fear has decreased, not because the risk to our immunocompromised patients has decreased, but rather because I recognize that this is the scenario; we’ve trained for during our entire NICU career. Anyone who has ever been in a NICU knows about strict hand hygiene and screening for early signs of illness. We have existed on the frontlines of every illness that could affect our neonatal patients for the past 100+ years.

I am concerned for the increased stress that parents of babies in the NICU feel. Having a child in the NICU is already an extremely stressful situation. If parents are allowed to visit, it is only one at a time. This creates an extremely isolating experience. The stress of the NICU is made even more traumatic in this time of uncertainty. I continue to be concerned for what seeing only half a face in a baby’s earliest experience might mean for their development. I see looks of confusion on my patients’ faces, but I know that the care I provide and the tone of my voice and compassion through touch is felt by my patients. I still see smiles from the babies and that gives me hope.

I have taken care of an infant with a COVID-19 swab pending. I’ve spent shifts being mindful of donning PPE in response to my patient. I’ve heard the mantra of “there is no emergency in a pandemic.” This does not feel possible when you see a baby with a decreased heart rate and oxygen saturation, which is why you become as efficient as possible in the donning of PPE. As has every other healthcare professional, I’ve experienced the effects of carbon dioxide retention. Nobody feels good at the end of a 12-hour shift spent in a face mask, but we step up to the occasion when an emergency arises.

This is Nurses’ Week and some restrictions are beginning to lift. I just want to encourage everyone to continue to be mindful, compassionate, and conscientious when beginning to reintegrate into the public. Wear the masks when you are out, maintain distance, and keep the household members going out to a minimum. Everything we can do to protect each other also protects the most vulnerable patients.