Nurturing Affective Development through Reflective Thought in

TwoCOVID-19-Themed

Scenarios *************************

I. The Longest Shift: Two Nurses’ Responses to an Unexpectedly Positive COVID-19 Patient on a ‘Low Risk’ Inpatient Unit

II. Oops My Bad…He’s Positive: The Impact of COVID-19 on a Nurse Colleague’s Mental Health.

Included: Nursing Self-Help Mental Health Screening and Wellness Toolkit Teaching Aid

David Foley, PhD, MSN, RN-BC, CNE, MPASusan Painter, DNP, PMHNP, PMHCNS, BC

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QSEN Teaching Strategy 1The Longest Shift: Two Nurses’ Responses to an

Unexpected COVID-19 Positive Patient on a ‘Low Risk’ Inpatient Unit

Authors: David Foley, PhD, MSN, RN-BC, CNE, MPA Susan Painter, DNP, PMHNP, PMHCNS, BC

Titles: Research Associate and Assistant Professor, RespectivelyInstitution: Case Western Reserve University Frances Payne Bolton School of NursingEmails: dmf106@case.edu

sgp30@case.edu

Author’s Disclaimer: This is a work of fiction. Unless otherwise indicated, all names, characters, businesses, places, events and incidents in this teaching scenario/strategy are either the product of the author’s imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.

Competency Categories: Teamwork and Collaboration, Safety, Patient-Centered Care, Informatics

Learner Levels: Pre-licensure ADN/Diploma, Pre-Licensure BSN, New Graduates/Transition to Practice, Graduate Students, Advanced Practice Providers, Continuing Education, Graduate Students, RN to BSN, Staff Development

Learner Settings: Classroom (small group discussion) or clinical settings (pre-licensure pre-/post-conference, preceptor-led discussion, or staff development session)

Strategy Type: General: to nurture affective development and promote reflective thought

Learning Objectives:

Through immersion in this clinical scenario, the student will engage in reflection and discussion to:

1. Affirm the importance of patient-centered care for patients and caregivers during the COVID-19 pandemic.

2. Identity opportunities to enhance effective teamwork/collaboration within a stressful COVID-19 patient care scenario.

3. Identify patient and caregiver safety as a top priority in COVID-19 related patient care scenarios.

Strategy Overview

Pre-licensure education is a complex process that involves the acquisition of knowledge, psychomotor skill, and affective ability within the didactic classroom nursing skills lab, and clinical settings, respectively. Although students often clearly recall efforts to assist them with gaining knowledge and skills through classroom exercises and lab ‘test-outs’, they may be less aware of efforts to promote growth within the more nebulous affective domain.

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o As a reflective exercise, this QSEN teaching strategy thus focuses squarely on affective development, providing learners with an immersive clinically-based experience involving the discovery of aCOVID-19 positive patient in a designated ‘low-risk’ clinical setting.

o Learners have the opportunity to read the actions and thoughts/perceptions of two registered nurses presented in hour-by-hour increments within an 8 hour shift.

o Reflective questions are strategically inserted following key events and are intended to be discussed—with corresponding instructor/peer feedback—in a synchronous manner.

o Whether in the classroom or clinical setting, learners should be granted no prior access to the scenario but given approximately one-half hour to read it independently, with peer interaction followed by instructor-facilitated discussion immediately following.

o A written Reflective Journal assignment follows the exercise’s conclusion and should be prepared and submitted to the instructor prior to the next classroom/clinical, or staff development session. The Reflective Journal is completed asynchronously and thus gives students a more discrete format to present the thoughts they might not have felt comfortable sharing in a public forum.

Scenario: Background

The onset of the COVID-19 pandemic took caregivers, hospitals, and the entire healthcare system by surprise. The acute and potentially lethal nature of the disease created a vacuum of policy, knowledge, and skill that required immediate attention. The authors’ current clinical work places them within a COVID-19 ‘low/reduced’ risk inpatient psychiatric setting as well as within portions of the ‘high-risk’ emergency/critical care continuum. Regardless of setting, however, the authors assert all patients require careful COVID-19 screening and ongoing monitoring, especially since many of them present for care with long-standing histories of transient housing, crowded living conditions, homelessness, and poor health-seeking behaviors.

The authors were very compliant with the new and rapidly-evolving COVID-19 policies that emerged during the spring and summer of 2020. They grew accustomed to careful, thorough screening as they entered the workplace, donned masks and other personal protective equipment (PPE), received training in wearing negative-pressure helmet headgear, and as new protocols for COVID-19 screening and ongoing monitoring, worked with other members of the interdisciplinary team to diligently watch patients for any signs/symptoms of COVID-19.

For example, one noted change from pre-COVID-19 conditions was a new inpatient vital signs protocol for the inpatient Psychiatric Unit, where vital signs were historically taken only once each day on this high-psychiatrically but low-medically acute unit. The new protocol required vital signs to be taken every shift and that any patient with a temperature >100.4 must be re-screened for COVID-19 via a nasal swab and then immediately isolated in their room with 1:1 monitoring while waiting for results to be returned. During the wait, the caregiver in attendance must quickly don and wear a self-contained negative-pressure helmet system, gown, protective footwear and gloves and remain in the patient’s room at all times. Due to a national shortage of such devices, only one self-contained negative pressure headgear system was issued per hospital unit, thus meaning any caregiver wearing the device who needed to leave a patient’s room, even if only to use the restroom, must remove and thoroughly sanitize the device before giving it to another staff member, who must in turn thoroughly sanitize it upon the original caregiver’s return. Once inside the patient’s room, the first priority for the caregiver is

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to obtain the COVID-19 swab and then use their portable communication device to summon another caregiver to pick up the specimen and take it to the lab. Since only a limited number of registered and licensed practical nurses volunteered for training in obtaining COVID-19 swabs, the number of caregivers qualified for 1:1 monitoring was quite limited on each shift.

As the pandemic progressed throughout 2020-21, processing times for a rapid COVID-19 specimen were noted to be at least 2-3 hours. As the care setting in this scenario takes place on an inpatient psychiatric unit, the patients’ rooms are only minimally furnished, meaning televisions, cell-phones, portable computers, hard cover books, writing implements, games, or other usual forms of diversional activity are not permitted. If the period of monitoring extends into a meal period, patients are provided only a bagged lunch as meal trays are also not permitted in the rooms. To date the protocol has been invoked 6 times and after each episode the caregiver in attendance anecdotally reported feelings of boredom and anxiety. Upon learning each of these 6 patients’ COVID-19 re-screening results were negative, the staff informed the patient they were free to leave the room, doffed and sanitized the negative pressure headgear, and returned their other assigned duties.

Setting

Although this immersive exercise takes place in an inpatient psychiatric setting, it can be used as a pre- or post-conference teaching tool in any course with a clinical component or as a staff development tool in any practice setting within the continuum of care.

Characters

Denise: a 32 year-old RN acting in the role of charge nurse. Her principle involvement in this scenario demonstrates her efforts to expeditiously retrieve a patient’s COVID-19 screening results and once the results were found to be positive, work to coordinate transfer of the patient to another care setting as quickly as possible.

Eric: a 58 year-old RN providing direct care to a patient requiring a rapid COVID-19 screening per the unit’s COVID-19 vital signs protocol. Eric’s principle involvement in the scenario involves the 5 ½ hour period he spent in the patient’s room while awaiting the COVID-19 screening results, followed by his efforts to swiftly transfer the patient to a more appropriate care setting.

Setting the Stage

The events in the following scenario occur during an 8-hour evening shift (i.e. 3:30pm-12 midnight)

As per usual practice, the shift began with nursing report, which consists of the outgoing charge nurse providing report in SBAR format to all members of the incoming shift assembled in the staff report room. The information provided for the patient discussed in this scenario (hereafter referred to as “Patient A” was simply “no change,” with no indication of any concerns about his psychiatric or physical status.

Immediately following shift report, Eric reported to the nurse’s station while Denise stayed in the report room to finalize the evening shift’s assignment.

The following table provides an overview of the shift broken down into one-hour increments and highlights Denise and Eric’s actions and commentary. The action pauses at key intervals to allow students and instructors to discuss one or more reflective questions.

Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary15:30-1600 During Shift Report,

Denise begins to make out the evening shift’s assignment for the 9 caregivers [a mix of Registered nurses (RN), Licensed Practical Nurses (LPN) and Nursing Assistants (NA)] on duty. In order to devote her full attention to this complex task, Denise asks Eric to “listen and take notes for her” and provide her with a 1:1 update following report.

“Even though we are an inpatient Psych Unit, our shift assignment document is quite complicated. I have to assign who will teach the patient groups, determine the order of admissions, assign patient rounds, and delegate several other duties. We might be Psych, but it’s not as easy as it looks.”

Listened to the outgoing shift report carefully. Looked over his notes to make sure they were complete and legible.

Eric made a copy of his notes for Denise and then let her know the shift report was essentially unremarkable. As was reported for a number of others, Patient A’s condition was reported simply as “visible on the unit, in good behavioral control and no change.”

Along with a number of other oncoming staff, Eric then moved to the Nurses Station to relieve the day shift staff so they could go home.

“I didn’t hear anything out of the ordinary about any of the patients, and especially those assigned to me. Nothing led me to believe this would be anything but just an average shift. I made sure I let Denise know I didn’t see any ‘hot spots,’ and that there were no impending admissions. She seemed relieved and continued to work on the assignment.”

“I make it a point to get to the Nurses Station as soon as I can so the outgoing shift could go home. Like most days, they really seemed in a hurry to leave, but that was ok with me because I like it when I can leave on time too.”

Reflection1. Keeping in mind the scenario takes place in an inpatient Psychiatric Unit, designated by the hospital as a ‘low risk COVID-19’ area, please

critique the outgoing shift’s report (i.e. do you think the information presented was adequate)? (Obj. 2)2. Upon opening any patient’s chart in the electronic medical record (EMR) a vividly-colored banner containing the most recent COVID-19

test results (including date) are listed first. Do you this is a sufficient means of exchange of COVID-19 information between caregivers? If not, what other information should be included and how should it be presented? (Obj. 2, 3)

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Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary1600-1700 Finalized shift

assignment by 1630 and provided copies to all staff. Sat down at the charge nurse desk and reviewed the roster of patients and their orders in the EMR to determine if there were any new/outstanding orders or specimens that needed to be collected.

“I make it a habit of double-checking everything right away to make sure nothing has been missed. Sometimes orders like EKGs, UAs, and lab specimens may also have fallen through the cracks and I do my best to make sure they are all completed or collected by the end of my shift.”

Introduced himself to Patient A and his other two assigned patients to review their orders and recent documentation. Provided a reminder twice to Veteran A to apply his face mask properly and to maintain appropriate social distancing. Met briefly with each of his three assigned patients to initiate a nurse-patient relationship and perform brief psychosocial assessment. Veteran A appeared more subdued than usual but was nonetheless communicative and appropriately responsive.

“I make it a point to introduce myself to my assigned patients as quickly as possible each shift. It’s a practice I have done for years and I feel it has served me well. Building trust, rapport, and an effective nurse-patient relationship takes work and starting early has proven to be an effective approach.

Veteran A seemed a little quiet, but I had been off for three days and sometimes the antipsychotics kick in it’s like meeting a whole new patient. I was happy he seemed to be doing better because the last time I talked with him he was really ‘out of it’. Like so many of our patients, I had to remind him like three times to put his mask on properly and to observe social distancing. Trying to get all of our patients to do that has been really challenging since this whole COVID-19 epidemic started.”

Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary1700-1800 Worked on

administrative charge nurse duties such as checking staffing for the next shift, noting possible discharges for the next day, and gave an update to the nursing supervisor. Denise first learned of Veteran A’s elevated temperature

“I felt so good about how things were going. For a change I wasn’t in a crisis-management mode and that I might be able to get ‘ahead of the 8 ball’ for once. I actually completed my charge nurse duties fairly quickly, and in retrospect I was glad I was able to,

While seated at the Nurses Station at about 1700, an NA whispered to Eric “I think Patient A had a temperature”. Realizing vital signs were not due to be taken for several hours, Eric chose to re-take the temperature himself. On approach, Eric had to again remind Patient A to

“I responded quickly to the information provided by the NA, as I value all forms of collaboration. As we forge working relationships with co-workers, we gain an understanding of their work habits. Since we were running a little short, she decided to work 4 hours overtime to help us out. I don’t know her very well, but she seems to be a very independent worker who doesn’t say much, so I took this act of communication seriously. I was glad I did after checking the

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about 1710 and assisted Eric with contacting the resident on call to give an update and determine next steps.

especially considering the events that would follow. When Eric told me a patient had a higher than expected temperature I wasn’t originally concerned, especially since I thought he might have just had some hot coffee. I was glad the resident on call reviewed the COVID-19 vital sign protocol and agreed with Eric’s plan for him to re-check the temperature in one hour. “

don his mask properly. Veteran A complied with the request to have his temperature (tympanic) taken and it was found to be 100.1. Eric confirmed the temperature in the other ear and then consulted the unit’s COVID-19 Protocol (see attachment). Eric notified the Charge Nurse Denise, who agreed he should contact the resident on call as a precaution. The resident agreed with Eric’s plan to re-check the temperature in one hour and then notify the Resident of the result. In the meantime, the Resident would consult with the attending Physician on call in case ‘next steps’ needed to be taken.

patient’s temperature. I just wonder why she felt she had to whisper. When I asked her later, she said she had told the RN on day shift and was not impressed by the response. The NA asked me not to say anything because she ‘didn’t want to get in trouble.’ I told her not to worry, but was a little miffed at my day shift colleague. If the temperature was reported, why didn’t they follow up?”

Reflection1. Consult the attached COVID Protocol. Do you think it was necessary to contact a resident for a temperature of 100.2F or should Denise

and Eric have waited until the 100.4F threshold was reached? (Obj. 1).2. What inter-personal factors might have stopped either of them from calling the resident? Prior to the COVID epidemic, do you think such

vigilance would have appeared odd? (Objs. 2 and 3)3. How would you respond when the NA expressed concern about “getting in trouble” for reporting Patient A’s temperature? How could a

hesitance to communicate impact safe and effective patient care? (Obj. 1, 2 and 3)Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary

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1800-1900 Learned of Patient A’s temperature re-check being 100.4 at 1810. Notified the Resident of the finding and after requesting an order to obtain a COVID-19 specimen, assisted Eric with donning negative pressure helmet system. Denise collaborated with Eric and both agreed the next steps were to obtain the COVID-19 specimen and transport it to the lab for processing.

“I was so glad that particular resident was on call. She was very proactive and had actually followed-through and called the medical director at home to let him know Patient A had an elevated temperature. The next half hour or so just flew by. Eric escorted the patient to his room and closed the door and asked him to wait there until Eric returned. Somehow I just remember Eric standing there with the negative pressure helmet system and watched him put it on. During other ‘COVID scares’ staff seemed to just run way but Eric jumped right in. That helped a lot. Eric had also retrieved a COVID-19 specimen kit from the supply room and then disappeared into the patient’s room. Once the door was closed, I felt really alone. Don’t get me wrong. There were other RNs on duty but I trusted

Patient’s temperature re-check taken and confirmed to be 100.4 F in both ears. The COVID-19 protocol was activated, Patient A was immediately escorted to his room and asked to remain there. In the meantime, Eric put on the negative pressure helmet and protective gear and picked up the necessary supplies for a COVID-19 specimen. Eric walked down the hallway, entered the Patient A’s room, and obtained the specimen as soon as Denise told me the order was ready. Using his portable communication device, Eric called for someone to pick up the specimen and an LPN arrived and took it to the Lab very quickly.

“I felt a rush of adrenaline as I prepared for the task of obtaining the COVID-19 specimen. I was very touched that two of my co-workers came over to help me ‘suit up’ and seemed to show genuine concern for my safety. From a more pessimistic perspective, I thought…could it be they were just being nice because they weren’t the ones who had to enter the patient’s room? Once the specimen was picked up, I turned off the patient’s lights and asked him to lay down so he could get some rest. He had already eaten dinner so there was nothing else to do. The room was spacious, and I sat about 15 feet from him on an uncomfortable chair and the wait began”.

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Eric and just felt I could count on him. I was grateful though, because I have three small kids and I didn’t want to be the one to go in there. I hope that doesn’t sound wrong, but it’s the truth.”

Reflection1. As a caregiver, how would you feel sitting in a darkened room while awaiting test results that can potentially impact the health of both

patient and nurse? (Obj. 2). 2. How would you answer this question strictly from the perspective of patient safety? (Obj. 3). 3. What questions would you ask if you were the patient? (Obj. 1). 4. What, if anything, would you say to the patient to comfort or educate him about his condition? (Obj. 2)

Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary1900-2000 Immediately asked a

nursing assistant to transport the specimen to the lab. Called the lab to insure it had been received and asked that it be processed as quickly as possible. Quickly toured the unit to check-in with the other nursing staff. Returned to the charge nurse desk to ‘take off’ orders and follow-up on three issues related to other patients on the floor.

“I knew getting the specimen to the lab was the highest priority. Until this point all previous “COVID scares” had resulted in a negative screening and the unit returned to business as usual. I hoped that was the case this time. Was in inappropriate to feel glad she wasn’t the one stationed in the room? With three small children, I would have been a nervous wreck. Then again, Eric takes care of his elderly parents and that is scary too. I felt

Positioned himself inside the patient’s room near the door and began to wait. Eric again used the portable communication device he wore around his neck to call Denise and letting her know he had settled in but she seemed to be a bit distracted. He could tell she was out on the unit talking to other people but learned she had already had someone take the specimen to the lab and would provide updates as they occurred.

“The patient seemed a bit agitated and I silent reminded myself I was working on an inpatient psychiatric unit. I had a growing concern about his agitation and asked him more than once ‘are you ok?’ He got really quite looked at me, and asked ‘am I going to die?’

As a nurse, I pride myself on working as a team member and using any and all resources—human, technology, knowledge, and expertise—to each patient’s advantage. I suddenly realized I was the only resource in the room and felt really awkward, struggling to find words of comfort to provide him peace. I did the best I could to tell him he was in good hands and asked him to please go back to sleep. At that point I don’t think he was feeling very well and seemed OK with

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guilty. Despite everything, I realized I was I charge of the floor and had to check on the other staff and patients. That was hard to do, but Patient A wasn’t the only patient on our floor and I had to tend to their needs too. I really hope Eric knew how much I was thinking about him though.”

trying to get some sleep”

Reflection1. From the perspective of safety, do you think it is necessary for a caregiver to remain with Patient A at all times while awaiting test

results? Would stationing a caregiver outside the door been equally effective? (Obj. 3)2. From the patient’s perspective, would you find this arrangement to be intrusive or would you want some privacy during this difficult

time? (Obj. 1)Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary

2000-2100 Continued with charge nurse duties while awaiting Veteran A’s test results. At 2030 walked down to Patient A’s room to say hello to Eric. After knocking, the door cracked open only slightly and the interchange, though meaningful and supportive, lasted only a few seconds.

“I did the best I could to continue with my duties but in the back of my mind all I could think about was Eric. I know Patient A’s needs were important, but as my colleague I really felt for Eric. I felt I really need to walk down the hallway and check on him. Eric cracked the door open slightly and seemed very surprised. He quickly assured me he was ‘ok’ and closed the door.”

Continued to monitor Patient A, who slept fitfully, once turning over and again calling out “Am I going to die?” Maintaining his composure, Eric assured Patient A that his results had not returned yet and that he was receiving appropriate medical care. Eric encouraged Patient A to back to sleep and within 15 minutes, he appeared to be sleeping soundly.

“I think this hour seemed to drag by the longest. I started to feel really cold, especially from the cool air circulating inside the helmet. I wish I had something to read, but I knew that wasn’t allowed. I just sat in the far corner of the room and hoped time would pass quickly. Out of the darkness I heard Patient A’s voice and it startled me. I kept myself as calm as possible, but what do you say to someone who asks if they are going to die? COVID-19 is so new I didn’t want to lie to him so I just told him that he was in good hands and to be calm. I felt like I really needed some additional training in comforting patients during difficult times. But then again, I assumed at any moment Denise

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would call me to say the results were negative and this would all be over.”

Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary2100-2200 Received a call at 2115

from Lab personnel stating Patient A’s COVID-19 test was positive.

Immediately placed call to the Resident on call, who indicated they would call the Medical Director at home.

Placed call immediately thereafter to the Nursing Supervisor, who had previously offered to contact Bed Control and facilitate Veteran A’s transfer to the Medical Intensive Care Unit.

“When I heard the patient’s test was positive I swear I almost fainted. Even though I was really upset for the patient, all I could think of was Eric sitting in that room all that time. How would I ever be able to tell him? I knew it was my responsibility to tell him but wow, what a challenge. I was very glad the Resident on call was very proactive and had already called the Medical Director at home and even more glad when she offered to call him again to break the news. I was also relieved the Nursing Supervisor offered to run interference in calling the Bed Control desk to speed up the transfer to the MICU. I felt I had enough to deal with here. The support was much appreciated. I called Eric as soon as I could on our

Continued to wait in darkened room. As patient seemed to have fallen asleep, Eric did not turn on any lights and simply waited.

Received notification from Denise at about 2120 that Patient A’s test was positive and that additional updates would be forthcoming.

Eric informed Patient A of the test results and that he would be transferred to the MICU would occur as smoothly as possible.

“The wait just became overwhelming. I know processing time of a rapid COVID-19 test is 2-3 hours minimum but that didn’t make it any better. Even though she was very calm, Denise’s voice seemed to just explode out of the portable communication device. When she told me the test was positive, I just turned cold. My thoughts raced as I thought about my loved ones. How could I be around them after this? Would I need to put myself in quarantine or just be grateful I was wearing the self-contained negative pressure helmet? Denise assured me they would do everything they could to get Patient A transferred as soon as possible. I guess for a moment I was very self-absorbed because out of the darkness Veteran A’s voice pleaded ‘what’s wrong? Was my test positive?’ I affirmed he had heard correctly but at the same time assured him he was in good hands and would be transferred to the MICU soon. He groaned but I was surprised how well he took the news. Somehow I think he knew the results were going to be positive and just resigned himself. I couldn’t believe it though. How could this have happened? I just assumed the test would be negative and everything would go back to normal.”

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portable communication devices and just told him ‘Patient A’s test was positive.’ I remember there was a very long pause and then he just said ‘ok’. That’s was it—just ‘ok.’ I let him know we would get to work and I would give him updates ASAP.”

Reflection1. The educator who demonstrated the negative pressure helmet system to Denise, Eric, and their colleagues said “I would rather be

wearing this device and sitting in an enclosed room with a COVID-19 positive patient than wearing a regular hospital-grade mask and be out in the general patient population.” Eric recalled this statement while he waited. Despite assurance of the efficacy of this technology, would you feel confident in this assurance of safety? (Obj. 3).

2. What would you say to Eric or Denise at this point in the shift? Despite Eric being in isolation with the patient, do you think there is anything else they could do to enhance teamwork and collaboration? (Obj. 2)

3. At this point what, if anything, might you say to comfort Patient A or enhance his sense of control in this difficult situation? (Obj. 1)Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary

2200-2300 Denise received word from the Nursing Supervisor that there would be a “delay” in transferring Veteran A to the MICU. The Resident on call informed the Medical Director and a series of tense, highly-charged phone calls occurred between the Medical Director, Nursing Supervisor, Resident, MICU charge

“When the Nursing Supervisor told me about the delay in transfer, I couldn’t believe it! We are a ‘low risk’ COVID-19 are and we now have a COVID-19 positive patient! ‘Let’s go,’ I thought, ‘if I have to transfer him myself I will at this point! I hadn’t really checked on the other patients on the floor very much and there

While Patient A drifted back to sleep, Eric began to feel increasingly fatigued and anxious, and waited for news of patient transfer. Eric was thirsty and had to use the restroom but decided to wait.

“I have to be honest. At this point I was just ready to scream. Does that make me less of a nurse? What was taking so long? I made the decision to remain in the room with Veteran A per protocol and although I could have used my communication device to call Denise or the Nursing Supervisor and asked to be relieved, I chose not to disturb my patient. Note to self: I hope I don’t have to do this anytime soon. How do people in the ICUs deal with this stress all the time? Even though I am angry this transfer is taking so long, I have to admit they deal with this stress every day.”

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nurse, and Denise. were more of their orders to verify. They had needs too. I was so behind and the stress was really getting to me! It just seemed like the MICU staff were somehow dragging their feet and didn’t want to take an admission this late in the shift. I didn’t know there was a time limit on taking care of sick people!”

Time Denise-Actions Denise-Commentary Eric-Actions Eric-Commentary2300-

midnightReceived word at 2300 that Patient A was approved for transfer. Called the ICU and was informed the nurse taking report would “call you back in a few minutes.” Denise again called the Nurse Supervisor to seek assistance with facilitating the transfer. The Nursing Supervisor contacted the ICU and a five minutes later the nurse taking the admission called Denise for report. Denise provided the required information, obtained a

“Enough already! Whenever we have to take report on an incoming patient from anywhere in the hospital, we are expected to do so immediately. Last week someone called to give report to us on an admission right in the middle of our shift report and when I asked if I could call them back in a few minutes, they reported me to the Nursing Supervisor, who told us to take report right away! I usually try to be nice but this has taken all shift and at this point I

Startled, Eric opened patient A’s door in response to a loud knock. Denise was standing there with a wheelchair and said “OK let’s go.” Eric called over to Patient A, who had been sleeping soundly and appeared dazed. Eric assisted him with re-adjusting his mask and moved the wheelchair closer to the bed. Eric provided some brief words of reassurance as he placed a blanket around Veteran A’s shoulders. Denise handed Eric an envelope, which he assumed contained any

“I have to admit I was daydreaming when Denise knocked on the door. She startled me! After waiting for so many hours, I was relieved just so see someone. I saw her standing there with a wheelchair and despite her mask, could tell she was smiling. It took me a few seconds to process she was actually there to pick up Patient A and that the night was almost over. I wasn’t in that big of a hurry when I called over to Patient A and asked him to get in the wheelchair. He was sound asleep and I didn’t think it was fair to ask him to rush just to suit us. Leaving the Psych Unit I was amazed at how good it felt to be out of that room. The bright lights and activity at any other time would have just been unremarkable, but today they comforted me with a sense of normalcy. When I got to the MICU and noticed a number of open beds I thought ‘wow, we

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wheelchair, and knocked on Patient A’s door.

decided this time it was my turn to call the Nursing Supervisor. I was so ready to get a wheelchair, grab the paperwork, and transfer Patient A! I can’t wait to go home.”

needed transfer paperwork. As he turned to leave, Denise squeezed Eric’s shoulder and said “thank you.”

Leaving the negative-pressure helmet and all protective gear in place, Eric quickly navigated through the hospital to the ICU’s entrance and after pushing the entry bell, was buzzed in. He was surprised to see several empty beds. As he walked down the hallway, Eric noted the time was 2330 and was informed Mike, an incoming night-shift nurse who just arrived for duty, would be taking the patient. Tanya, the ICU’s charge nurse, asked Eric for the envelope and took control of Patient A’s wheelchair and walked away. Eric quickly walked after the wheelchair to wish Patient A the best and then left the unit.

Upon return to the

waited all this time for what?’ but I realized I don’t work there and didn’t want to judge—well not really at least. I thought the charge nurse looked really irritated and I wasn’t in the mood to engage her. Maybe on another day but not now. When they told me an oncoming nurse was taking the patient, all I could do was wonder if they stalled just so none of them would have to do the admission. Does that make me sound bad to think that about my MICU colleagues? Just then I realized I should say something to Patient A, maybe some words of encouragement or comfort, or maybe just a ‘good luck.’ They seemed in a rush to get him into the isolation. OK now they decide to be in a hurry!

When I got back to the Psych Unit all I could think of was getting out of that helmet, sanitizing it, and getting it back to its storage location. It felt so good to have the air touch my face. Even though I knew Denise might still be in report, I went to find her, maybe just to hear a few words of empathy myself. I swear when I walked in to the report room some of friends on the oncoming shift avoided my gaze and appeared uncomfortable to be around me. I thought I even heard of them say ‘that bathroom needs to be cleaned now’ after I came out from washing my hands. Denise and I didn’t say much as we walked to our cars. I knew we would talk about the experience another day

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Psychiatric Unit, Eric removed all protective gear, sanitized the helmet, and then looked for Denise, who had just finished giving the oncoming shift report.

Eric washed his hands several times in the staff restroom and then walked to the parking garage with Denise with very little conversation. Both said good-night, got in their cars, and left.

but for now, I just wanted to go home, take a shower, and wash the day off me.

Then the thought hit me: I had just sat in an enclosed space with a known COVID-19 positive patient for several hours. Did I have anything to worry about? I thought again about the sales training rep who said ‘I’d rather be in an enclosed room wearing this self-contained negative-pressure headgear with a COVID-19 positive patient than in than out in the unit with patients wearing regular masks.’

Only time would tell.”

Before reviewing the following questions, please read Denise and Eric’s final reflections that follow this scenario.

Final Reflection1. How would your own sense of control be challenged if you waited several hours for your patient to be transferred? (Obj. 3) If your

patient expressed fear or any other concerns during the wait, how would you have responded? (Obj. 1).2. Critique the teamwork and collaboration that occurred during the transfer. Do you think Denise and Eric supported each other

effectively? How could they have improved? (Obj. 1)3. Critique the teamwork and collaboration between Denise, the Nursing Supervisor, Resident and the MICU staff. How would you react

to the actual—or perceived—structural or organizational barriers Denise faced when facilitating the transfer? (Obj. 2).4. Given the relative uncertainty of caring for a COVID-19 positive patient, do you feel safety, specifically g minimizing risk for COVID-19

transmission, should be the only priority in providing patient-centered care? If not, then what other factors should be taken into consideration? (Objs. 1 and 3).

Post-Scenario Character Reflections

Denise

“The biggest lesson I learned from that long shift was the importance of teamwork and collaboration, especially validating the people you can truly lean on in a crisis situation. I feel grateful that Eric was there that day, and I kept asking myself that if I hadn't been working with him, would the outcome have been the same. The long, exhausting 8 hour journey was surrounded with emotions based not only on doubts about knowledge or skill, but on the foundation of trust and commitment in my co-workers. Who wouldn’t have doubts about this moment of uncertainty? I feel our team captured what it means to fully commit to the challenge of providing good patient care and insuring the safety of others.

I also thought about attention to detail and how double checking always pays off, especially for safe patient-centered care. Immediate follow-up on the patient’s elevated temperature meant prompt action and helped to minimize the exposure of other patients. Without effective follow-up on the NA’s suggestion to re-check the temperature we wouldn't have known about it until at least 8 pm, when evening vital signs are routinely taken. My thoughts when Eric came back and told me about his elevated temperature was to stay calm and to act quickly and decisively, which we did. We communicated the facts to the resident on call and collaborated by reviewing the COVID-19 protocol making a plan to re-check the patient’s temperature in one hour. In that regard, I don't think events could have gone any better or more smoothly than they did. I remember staying calm and continuing to also focus on other charge-nurse tasks to make sure all other patients and caregivers were ok and that, the shift’s assignments were being carried out correctly.

Doing all of those tasks was not easy, especially as I remember our acuity was high. Patient after patient came up to the charge desk window ask for things, even the smallest things like water or changing the channel on the unit’s only communal TV. I remember that hour before the temperature re-check so clearly, but at the same time I juggled so many small patient requests that before I knew it, Eric was standing next to me telling me the re-check was 100.4 F. He also told me he confirmed the temperature twice in both ears. There was no denying the patient’s temperature was at the threshold to start the COVID-19 protocol and right then and there, some fear set in. I knew we needed to act fast, get the patient to his room and station a staff member in the room with him and isolate him per protocol. Eric did not hesitate at all. Before we could even figure out who could go in, he offered. I knew I could count on him but at the same time, I was scared and felt guilty. Guilty because I know he has elderly parents and had to go in there in an enclosed room with a potentially COVID-19 positive patient and guilty again because I was glad it wasn’t me. I had no idea Eric’s being stationed in that room would turn into such a marathon event. Then again, I feel for safety we moved to implement the COVID-19 protocol quickly and just trust in each other. We depended on each other as team members.

Once he put on the negative pressure system/protective gear and stationed himself in the room, some anxiety set in. In my head I started to think of all the people and things I needed to accomplish. I was also thinking very frequently about Eric being in that room. I called the resident on call first and remember talking to her several times and also calling Eric on our communication devices and sometimes trying to talk to both at the same time. Once Eric collected the COVID-19 nasal specimen and I sent it to the lab, the only thing we could do was endure the long wait. It made it challenging to stay focused knowing that Eric was in the patient’s room. I called him to make sure he was ok, and even

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though he assured me he was, I still felt uneasy because I just wanted to get him out of the room as quickly as possible.

Once I could stop and take a minute to gather my thoughts, I finally was able to think about my own family and my 3 small children. I started to worry, knowing I had direct contact with the patient earlier in the week and had even taken his vitals in his room the night before. In my mind, I kept thinking ‘he will be negative…he will be negative. All of the other COVDI-19 scares had come out ok. This will all be ok too. No matter what, it will all be ok’.

But then the unthinkable happened. His test came back positive and I felt this rush of anxiety. I remember having a huge pit in my stomach and just feeling shocked. This was our first ever COVID-19 positive case on our floor. How could this be happening? Eric! I felt I needed to stay calm and call Eric right away. I didn’t want to call, but I felt Eric needed to know right away. But to be honest, I notified the Resident on call first so she could, per hospital policy, start the process to get him transferred to the MICU, all the while feeling numb and in complete shock. There were so many questions! This had never been done before on our floor but I think I just did what we needed to do...called the Resident, notified the Nursing Supervisor, and called the attending in charge of the floor—at home!

After some initial positive communication, I encountered some resistance that seemed to get worse as the time drew closer to actually transfer him. What was going on? This was most certainly the most challenging part of the whole evening, especially since it was almost the end of our shift. Our collective anxiety was at its highest. An RN co-worker assisted me with handling many calls to the Nursing Supervisor, Bed Control, the MICU nursing staff, the Resident on call, the Medical Director, and even our own Nurse Manager, who had been contacted by the Medical Director. I first thought the MICU nurses were just dragging their feet and just didn’t want to take another admission this late in their shift, especially a COVID-19 patient. But then again, after speaking with the Nursing Supervisor, resident on call, and our Nurse Manager, it seemed that everyone was taken by surprise that our floor had a COVID-19 positive patient. After all, he had been on the Psychiatric Unit for over 10 days and had initially tested COVID-19 negative on admission. I’m sure I wasn’t the only one thinking “how did this happen?” or “what about the other patients and staff.” In the end, everyone seemed to rally and the Patient A was finally transferred off the floor at 11:30pm.

This shift was by far the most difficult shift I have ever experienced as a nurse or charge nurse for so many reasons. With a pandemic, fear of the unknown is inevitable, but sometimes we have to set aside that fear in the interest of providing good patient care and maintaining safety. I know it was normal for me to feel many of the emotions I had that night and I had to give myself some grace because I honestly left the hospital that night feeling doubtful of myself. Did I do enough? Did I do everything the right way? Was I supportive enough?

It took me a number of days to shake off the stress of this shift but I don’t think I ever really got over it. The only people who could understand were those who experienced it with me. I really wish I had someone to talk to help me process the stress and help me move forward. No one contacted me about any follow-up testing and I had to call Employee Health and arrange for my own test. I was relieved when my own COVID-19 test came back negative but I don’t know if I will ever trust the system or feel at home on my unit again.

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Eric

The shift started out very routine. I remember going about business as usual. I usually make it a habit of introducing myself to each of my assigned patients right after shift change so they know who to ask for and so I can begin the process of building rapport and trust. I know that may sound a bit text-book, but I strongly believe in scheduling my days as defined by what we learned in school: the Orientation, Working, and Termination Phases of the nurse-patient relationship…just how I learned in the Nursing Theory course in my pre-licensure nursing class.

All was going well, almost too well. After I finished speaking with Patient A, an NA I trust came up to me and whispered “check his temperature.” I am glad I listened. Many RNs and LPNs I have worked with would not have reacted, as somehow they just might not take feedback from an NA seriously. Maybe sometimes I’m even like that, but I have a lot of respect for Tanya’s work and she hardly ever approaches me so when she did, I knew it had to be important. She is one of those Nursing Assistants who is very diligent about her duties so when she spoke I hit the pause button on whatever I was doing at the moment and listened. I went and re-checked Patient A’s temperature and found it to be high almost to the point of the COVID-19 Protocol’s threshold. I was very concerned because it had been a struggle to have Patient A keep his mask on and I had seen him sitting fairly close to other patients without his mask. As I approached him to check his temporal temperature, he had his mouth and nose uncovered and with his mask dangling from his left ear. I checked the temperature in both ears and let Denise know we should tell the Resident right away. I really like working with Denise because she just “gets it” and is very meticulous. Before I knew it I was sitting in Patient A’s room wearing the negative pressure helmet. As soon as I could, I took his COVID-19 nasal swab and the wait began. I remember being so cold, especially from the air blowing inside the helmet. The room was dark too. Patient A had to wear his mask and given the fan’s noise inside the helmet, it was hard to hear or communicate. Patient A actually said he wasn’t feeling well and wanted to lay down. I turned off the overhead lights and sat there with only a single night light. Before he drifted off to sleep Patient A asked me very directly “am I going to die?” and I was so conflicted. Of course I felt I should offer him words of reassurance like “you’re in good hands. There’s really great doctors and care in this hospital” and “we are going to take good care of you,” but I just couldn’t say what I wanted to say and that was “of course not! You are not going to die” because the truth was a lot of people have died from COVID-19 I’m sure that, despite his psychiatric symptoms, even he knew that.

Once in a while Denise called me on the small communication device we all wear. Her voice sounded so loud in the quiet room, but it was good to hear from her. It was so lonely sitting there but I knew she was working hard as she always does. The truth is, we had experienced similar scares like this on the unit before but the results were always negative and it was back to business as usual.

After a long wait I heard her voice again and she sounded a little different and she told me the results were positive.

I regretted I couldn’t stand out in the hallway so she could tell me privately. Since I had to stay in the room, Patient A and I both heard the results at the same time. Denise told me she had spoken with the Resident and Medical Director. After the notification both Patient A and I just sat there in silence.

‘What’s going to happen to me now?” he asked? “What’s going to happen to me?’

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What’s going to happen to me? I thought. Am I going to take this illness home to my elderly parents? Will I have to quarantine? Who will take care of them?

‘Come on man, talk to me!’ Patient A called out, bringing me back to the present/

Everything is going to be fine, sir. We are going to transfer you to one of the other Units where you can get the medical attention you need. Just relax and get some rest. That was all I could muster but to be honest, I later thought an experienced Psychiatric nurse should have done better than that.

He was scared and I have to admit, I was too.

What’s taking them so long? I asked and as the time went on, I started to fume. I definitely felt this transfer should have been much faster, but I had no idea what was going on in the ER or Units. Maybe the acuity is high or al the beds are full or worse yet, the nurses are stalling so the next shift will have to take this transfer…

Following an intense knock, I opened the door, which by this time felt was like opening a time capsule. The hallway lights were momentarily blinding, but I was comforted by Denise as she stood there with a wheelchair.

It was almost over.

“Come on Patient A,” I heard her say, “it’s time to take you to the next stop” she said cheerfully and then lowering her voice as she handed me the envelope containing the transfer paperwork, said “he’s going to the MICU.” Patient A got into the chair and we were quickly on our way. I left the negative pressure helmet on as I walked through the nearly deserted hallways. It was 2315, nearly 7 hours since I had taken Patient A’s temperature. I dropped him off at the nearly empty MICU and was told by the charge nurse that an incoming night shift nurse would be taking him.

‘Ha,’ I thought, maybe they were stalling after all. I did my best to provide some words of comfort to Patient A but sensed the MICU’s charge nurse was becoming impatient, so I just left. I assumed Denise had provided report but didn’t want to assume that. I’ll have to ask her after I get back, use the restroom, and have some water. I took the helmet off even as I entered the Unit. I took it directly to its storage location and took a full five minutes to wipe it off carefully so it would be ready for the next person at a moment’s notice. My co-workers seemed to all back away from me just a bit as I re-entered the nurses station, but perhaps that was my imagination and at that point I didn’t care. I just wanted to go home.

I really wanted to talk to Denise but I sensed she just didn’t want to discuss it. I knew it had been a long shift for both of us, but in very different ways. We walked to the parking garage without saying much. I had hoped we could really sit down and process the experience as a team but no one really seemed to want to talk about it.

For some reason, I expected to get a follow-up call from my Nurse Manager or Employee Health the next day, especially since this event was to novel for our ‘low risk’ COVID-19 unit. No one ever called so about 2 days later I called Employee Health on my own and felt like I had to actually talk the physician into ordering a COVID-19 screening for me. He said wearing the helmet placed me at ‘minimal risk’ for transmission but finally approved the test. I was relieved it was negative and resolved to discuss this incident as little as possible.

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Submitted Materials

Inpatient Unit COVID-19 Isolation ProtocolReflective Journal Format

Evaluation Description

1. Instructor verbal and written feedback to clinical performance and Reflective Journal response.2. Student-peer verbal feedback to during pre-/post-conference discussion.3. Demonstration of ability (empathy and therapeutic communication)—with instructor and/or

peer feedback-- in the clinical setting

COVID-19 Vital Signs Isolation Protocol (A unit new Psychiatric Unit-specific policy that is also included as a written order in patient’s electronic

medical record and thus available for review by all members of the healthcare team).

Take TPR/BP Q Shift. If temp > 100.4, first confirm the reading and continue medical/surgical mask on pt.; isolate the pt. to their room w/ 1:1 staff monitoring (staff must wear negative pressure helmet system) and notify provider immediately.

Student Reflective Journal FormatAt the discretion of the instructor, the following questions can be provided to students verbally, in writing, or posted as discussion questions within the course’s online learning management system.

After reading Denise and Eric’s final reflections, read, thoughtfully reflect, and answer the following:

I. Reflect on your overall experience with this COVID-19 reflective exercise as related to your own COVID-19 experience(s).

II. How has the arrival of COVID-19 challenged the knowledge or skills you have acquired in the nursing classroom or skills lab?

III. How have challenges presented by COVID-19 impacted your ability to care for patients in the clinical setting? Do you feel prepared to provide comfort to patients facing this and other potentially life-threatening illnesses?

IV. Given the arrival of vaccines, the world is hopeful the COVID-19 pandemic will end soon. Moving forward, how may clinical scenarios similar to that experienced by Denise or Eric impact your future nursing practice?

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QSEN Teaching Strategy 2

Oops! My Bad….He’s Positive!COVID-19 Related Workplace Stress on a Nurse Colleague’s Mental Health: A Reflective Exercise

Authors: Susan Painter, DNP, PMHNP, PMHCNS, BC and David Foley, PhD, MSN, RN-BC, CNE, MPA and Title: Assistant Professor and Research Associate, RespectivelyInstitution: Case Western Reserve University Frances Payne Bolton School of NursingEmails: sgp30@case.edu

dmf106@case.edu

Author’s Disclaimer: This is a work of fiction. Unless otherwise indicated, all names, characters, businesses, places, events and incidents in this book are either the product of the author’s imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.

Competency Categories: Safety, Teamwork and Collaboration, Informatics, Quality Improvement

Learner Levels: Pre-licensure ADN/Diploma, Pre-Licensure BSN, New Graduates/Transition to Practice, Graduate Students, Advanced Practice Providers, Continuing Education, Graduate Students, RN to BSN, Staff Development

Learner Settings: Classroom (small group discussion) or clinical settings (pre-licensure pre-/post-conference, preceptor-led discussion, or staff development session)

Strategy Type:General: to promote reflection and nurture affective developmentRole play: nurture affective development and therapeutic communication skills

Learning Objectives:

Through immersion in this clinical scenario, the student will engage in reflection and discussion to:

1. Identify opportunities to enhance collaboration, teamwork, documentation (informatics), and patient-centered care when providing care to patients with/suspected of having COVID-19.

2. Review and reflect on the importance of consistent policy implementation and vigilant screening to promote safety when caring for patients COVID-19.

3. Reflect and discuss the effects of prolonged stress and uncertainty on the mental health of nurses caring for COVID-19 patients.

Strategy Overview

The COVID-19 pandemic has presented many unique challenges for students (pre-licensure and APRN), faculty, and practicing nurses. The rapid onset of this crisis required swift changes to both policy and practice, with many opportunities to exercise effective collaboration-teamwork, and patient-

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centered care practices as well as utilize informatics to properly document those efforts. As opportunities for direct student-patient interactions in the clinical setting have significantly decreased during the COVID-19 crisis, simulations followed by meaningful debriefing and reflection have once again been affirmed as an efficacious pedagogical tool that allows for virtual immersion into low-incidence, high-risk scenario.

As is the case with this scenario:

o As a reflective exercise, this QSEN teaching strategy thus focuses squarely on affective development, providing learners with an immersive clinically-based experience involving the discovery of aCOVID-19 positive patient in a designated ‘high-risk’ clinical setting.

o Learners have the opportunity to read the actions and thoughts/perceptions of two registered nurses presented in hour-by-hour increments within an 8 hour shift.

o Reflective questions are strategically inserted following key events and are intended to be discussed—with corresponding instructor/peer feedback—in a synchronous manner.

o Whether in the classroom or clinical setting, learners should be granted no prior access to the scenario but given approximately one-half hour to read it independently, with peer interaction followed by instructor-facilitated discussion immediately following.

o A written Reflective Journal assignment follows the exercise’s conclusion and should be prepared and submitted to the instructor prior to the next classroom/clinical, or staff development session. The Reflective Journal is completed asynchronously and thus gives students a more discrete format to present the thoughts they might not have felt comfortable sharing in a public forum.

o Lastly, learners are asked to consider the main character Denise’s stress response and mental health status by engaging in a role play. In doing so, they attempt to use the provided ‘Nursing Mental Health Resource Guide’ to assist her in gaining insight into her current condition and encourage her to seek assistance. Perhaps in doing so, they will also use her status to reflect on their own COVID-19 stress response.

Setting the Stage

The scenario occurs in a busy urban Emergency Department (ER). Due to short-staffing caused by the COVID-19 Pandemic, Denise, a staff member from the acute inpatient Psychiatric Unit, has been required to take her turn to ‘float’ to the ED to provide care for two acutely ill psychiatric patients.

Timeframe

The scenario unfolds during a busy Friday evening shift, in this hospital defined as 15:30-midnight.

Characters

Denise: a 32 year-old RN acting in the role of bedside nurse. Denise works on the inpatient Psychiatric-Mental Health Unit but was floated for her 15:30-midnight shift since two psychiatric patients are

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currently under observation in the Emergency Department. Upon learning it was her turn to float, Denise was tempted to go home sick, but steadied herself and stayed. She was recently deeply affected by a COVID-19 patient-scare several weeks ago on her own unit. Since that time she has experienced episodes of acute anxiety, insomnia, bouts of depression, and difficulty concentrating. Denise is in her second semester of a demanding Psychiatric-Mental Health Nurse Practitioner Program and is also beginning to feel the stress of competing work-school-life demands. “I was already feeling the effects of the stressful Psych NP Program. I think the constant ‘COVID stress’ has just made things much worse.”

Jason: a 45-year-old RN who has spent his entire career in the Emergency Department. Jason is known as a highly-competent nurse with an easy-going manner. His work in the Emergency Department has placed him on the front lines of the COVID-19 pandemic and so far he managed to remain resilient and deal with the stress very well. “It something’s going to happen, it’s going to happen I guess” is his mantra. Denise met Jason once when she floated to the ER a year ago but otherwise has only spoken to him to take report on patients who are ready for transfer to the Psychiatric Unit. Jason was glad to see Denise walk into the ER. “If someone had to float, I’m glad it was Denise. I know she’s a great nurse and will take good care of these two Psych patients.”

Time Denise Commentary Jason Commentary15:30-1600 Arrived at 15:30 on the

Inpatient Psychiatric Unit. After rushing to stow her belongings and enter the report room, the Nurse Manager informed Denise it was her turn to float to the Emergency Department (ED), specifically to care for two psychiatric patients on observation status. Denise took her lunch and moved as quickly to the ED as possible.

“I was in such a rush to get to work. Wouldn’t you know it—the COVID-19 screening line was backed up. I become so frustrated because the screening process is a constant reminder of the dangers of COVID-19. I honestly haven’t felt the same about this place since I was exposed to a COVID-19 patient on my own unit a few weeks ago. Now today I have to float. I really don’t like floating, especially to the ED. I feel so out of place there.”

Arrived at 15:15 to the Emergency Department. Learned he would assume charge nurse duties due to a call-in. Quickly scanning the patient roster, Jason asked his Nurse Manager to request at least one float.

“I got to work and heard we were really short because of call-ins. The Nurse Manager just got back from a meeting and I asked him to work on getting us a float. I took report on both psych patients. Nobody else wanted to take them so I just said whatever…I’ll do it. I think everyone’s hang-up is that if there’s no sitter or nursing assistant around to monitor them one on one then the RN has to do it. Since they’re in individual enclosed cubicles, I don’t see what the big deal is. I leave the curtains wide open and keep an eye on them from the Nurses Station. That has always worked until they could get me a sister. Luckily Denise showed up around 1545 so I gave her the two psych patients while finished making out the assignment.”

Reflection1. Consider the last time you ‘floated.’ Did you feel welcomed or out of place by the receiving unit’s caregivers? What specifically made

you feel the way you did and how did your impressions impact teamwork as the shift progressed? (Obj. 1).2. Do you think ‘no floating’ to high-risk areas like the Emergency Department should be implemented during the COVID-19 pandemic?

How might such a policy positively—or negatively—impact patient care? (Obj. 2)Time Denise Commentary Jason Commentary

1600-1700 Quickly took report on her two assigned patients, both of whom were under observation for expressed suicidal ideations. Despite Jason assuring her it would be “ok” to monitor both

“I honestly didn’t know where to begin. The psychiatric observation rooms are at the far end of the unit and I just didn’t feel safe. I introduce myself to my

Received news a new cardiac patient had just arrived by stretcher. Quickly gave Denise report on the two psych patients and assisted the ED

“I was really glad Denise showed up. She floated down here once before and I know she’s a great psych nurse. Psych patients just really aren’t my thing. They make me feel like I’m just babysitting. Denise looked a little stressed sitting on a chair in the hallway. I know she did that so she could keep an eye

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patients from the nurses station, Denise took a chair and positioned herself in the hallway so she could monitor both patients from just outside their glass cubicles. When Jason returned he assured her he would be in close proximity so she decided to begin her assessments.

patients and sat down in a chair in the hallway. Awkward! I know Jason said it would be OK to watch them from down the hall, I didn’t feel comfortable doing that, even though they were in cubicles with the doors wide open. Jason returned a few minutes later while a technician worked on a patient he picked up. Lucky Jason! They give me two psych patients with no sitter.”

physician with triaging the cardiac patient. Learning the patient might be more stable than first thought, Jason asked the technician to draw blood and obtain an EKG while he went to check on Denise.

on both patients at once though. I really wanted to tell her to just relax and come and sit at the nurse’s station, but decided this wasn’t the time.”

Time Denise Commentary Jason Commentary1700-1800 Denise told Jason she would

start her assessments. Jason assured he would remain in the area and encouraged her to continue.

“By the time we receive an admission to the inpatient Psych Unit they have already been in observation in the ED for up to a day. They’ve usually had some medication and have always had a negative COVID-19 test. Being here meant I was right on the front lines and I just really freaked out. I hoped no one could tell. I actually sat in the hallway not only to watch my patients but

Moved to a computer behind a desk about 15 feet from Denise. Offered Denise supportive encouragement and answered a few basic questions about ED workflows. Informed Denise both patients had been negative COVID-19 screenings.

“Denise looked really uptight when I saw her. She strikes me as the type of nurse who likes to get her work done and out of the way. She asked me if both patients had negative COVID-19 tests and I knew they both had without looking. Based on our workflow, most patients receive a rapid COVID-19 test, especially if it looks like they might be headed for the Psych Unit. They usually don’t make it back to one of the 24 hour observation beds until they have tested negative. That’s just our workflow and how we have always done things.”

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also to put myself as far from the medical beds as possible. I have three small kids at home and just can’t risk taking anything home to them. I didn’t look up my patients in the computer. I decided to wait until one of the workstation on wheels (WOWs) were available. I asked Jason if both patients had negative COVID test results and he assured me they had. I decided to just do my assessments verbally and document them later.”

Reflection1. Observing that she was stressed, do you feel Jason should have done an emotional check-in with Denise at this point? What factors might

have impacted his decision to speak—or not—speak with her? (Obj. 3)2. Do you feel Denise’s decision to assess her patients verbally and then access the EMR later is sound? Do you feel the stress she is

experiencing has impacted her performance? (Obj. 1 and 3)3. Would you have accepted Jason’s verbal assurance that both patients’ COVID-19 results were negative? Do you feel verbal

communication among team members might be a norm in the ER’s often highly intense work environment? (Obj. 1)Time Denise Commentary Jason Commentary

1800-1900 Entered Patient C’s cubicle (an assessment room with 3 solid walls and 4th wall consisting of a large sliding glass door) to find his mask lying on the floor. Denise

“This is just great. I enter this small room only to find my patient without a mask. How long had he been in there without one? I

Updated cardiac patient’s family in the waiting room. Checked on cardiac patient, only to find him sleeping soundly. Jason sat back

“I’m not sure how this happened, but it did. Trust me, patients are not usually moved to the psychiatric observation beds until they have a negative COVID-19 test. I mean at that point they are one step away from being admitted to the unit and they can be held

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quickly retrieved a new mask and handed it to him. Patient C donned it but left his nose exposed. Denise sighed and remained standing in the doorway about 8 feet from the patient for approximately 20 minutes while she completed her assessment.

really didn’t care that he had a COVID-19 test. He should still be wearing a mask. Look what happened upstairs on the unit. That patient had a negative COVID test but the converted to being positive while on the unit. He might already be positive but asymptomatic. I know I need to give good patient care but I just want to get these assessments over with as soon as possible”

down at the nurse’s station and prior to documenting. The phone rang and it was the lab, calling with the news that Denise’s Patient C’s COVID-19 test results were positive. Jason confirmed the results with the lab staff and then hung up the phone speechless.

there for up to 24 hours. They almost never are placed in those rooms until they have tested negative, especially since they can be admitted to an inpatient bed as soon as one becomes available. They need to be ready to go in case we have to transfer them quickly to open another Psych holding bed. Poor Denise—she’s going to really freak out. How am I going to tell her?”

Reflection1. Do you find Jason’s statement “oops my bad…he’s positive!” to be inappropriate or simply an effort to diffuse a highly stressful and

awkward situation? (Obj. 1). 2. At this point in the scenario, what policies should be in place—and consistently followed—to promote effective communication and

safety? (Obj. 2).Time Denise Commentary Jason Commentary

1900-2000 Finished both assessments and was informed a sitter would be arriving to assist her at 2000. Denise saw an unused WOW in the hallway and retrieved it to begin documenting. Learns from Jason that Patient C is COVID-19 positive.

“I was glad I finished my assessments. They weren’t that bad and I actually wondered if one or both of the patients might be sent home and not even admitted. Jason called me over smiling. ‘Some good news, I thought.’ I heard him say ‘oops my

Informed Denise of Patient C’s positive test results by saying lightheartedly “oops my bad….he’s positive.” Called the Nursing Supervisor to request supportive guidance.

“Poor Denise. I think it really freaked out when I told her one of her patient’s was positive. I guess we look at things different down here on the front lines. Several of the ER staff had already had COVID but I have been lucky and haven’t had it yet. I could just kick myself but things just happened so fast. I was supposed to take those Psych patients but then Denise floated down and she took them and everything happened so fast. I assumed everything was ok”

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bad…he’s positive. Please don’t freak out on me, it’s no big deal.’ I heard him say these things but it took a few seconds for the words to register. Without being told I immediately knew he was referring to Patient C. I just turned around and walked away until I found a chair around the corner. I sat down shaking.”

Reflection1. At this point, what actions should Jason take to insure safe and effective patient care as well as support Denise’s emotional and physical

well-being? (Obj. 1 and 3)2. If you were in Jason’s role, would you treat this as an exposure incident and if so, what policies would you anticipate consulting? (Obj. 2).

Time Denise Commentary Jason Commentary2000-2100 Tearful, Denise called the

Nursing Supervisor without consulting Jason. She asked for clarification on COVID-19 testing for herself as well as to inform the Supervisor that a COVID-19 patient had been identified and would need to be transferred to the MICU.

“How could this happen? I have 3 small children at home and now I may have been exposed to another active COVID-19 patient. What am I going to do?

As a nurse I understood the risks of working in an environment with COVID-19 patients. The possible exposure incident on my home

Sensing Denise’s high level of concern, Jason called the Nursing Supervisor again to inquire about follow-up care for Denise. The supervisor seemed very irritated about the multiple inquiries.

Jason walked over to Denise to offer an apology and words of encouragement.

“I wish the Nursing Supervisor had been more supportive or offered to stop by. Come to think of it, they really don’t come to the ER very often unless absolutely necessary. Maybe they avoid our area because of COVID-19.

I will be in the hot seat because of Denise’s potential exposure and I am sure they will attribute to poor communication on my part. But I guess they are right. I should have checked in the chart and I own my mistake. Then again, isn’t it every employee’s responsibility to protect themselves? I’m sure

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unit several weeks ago was bad enough but now this—I just spent a significant amount of time speaking with this patient in a very small space. I really need some guidance here. He was breathing inside that cubicle without a mask for a long time and then didn’t apply his mask properly when I gave him one.

After speaking with the Nursing Supervisor, I found a phone at a desk one workstation over and called my mom and just cried. I felt so scared and stressed. I stumbled down the hallway and found a chair around the corner. Someone please help me!”

Denise appeared tearful and not at all receptive to talking.

we will be sorting this out for a long time. I think she should have found a computer and looked her own patients up. If she saw the results were positive—or still pending—then she too could have raised a red flag.

In the meantime, I will need to fill out an unusual incident report, notify the nurse manager, and most of all, try to get this patient out of here. Since he is actively suicidal, I’m sure the MICU will not be thrilled to have him. He’s going to need a sitter.

I will call Bed Control first so they can find an open MICU bed and get the transfer process started. I will also run across the hall to see the Resident so they can write the orders. The sooner this is done the better. For now, damage control with Denise will have to wait.”

Time Denise Commentary Jason Commentary2100-2200 The Resident on call

approached Denise at 2230 indicating the transfer orders have been written.

Denise quickly followed-up

“If there was one bright spot in this horrible evening, at least the Resident on call was able to write the transfer orders quickly. I

Contacted the resident on call and asked for help in getting transfer orders written.

Called a friend on the

“I tell you, it pays to be nice to people. The resident on call was just great. She dropped everything and put the transfer orders in. My friend on the unit was also just spectacular in breaking up any log jams in getting us a bed. I was really happy to let Denise know but she

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with Bed Control and was given the MICU bed number. She called the MICU and gave nursing report immediately.

remember what a nightmare it was a few weeks back trying to transfer that COVID-19 positive patient from the inpatient Psychiatric Unit. I just hope the MICU nurse will take report so we can get the patient out of here much faster than the last time. I guess that may sound mean, but he needs to be in a care setting where his COVID-19 symptoms can be managed. Or is it that I just don’t want to be around him any more for my own safety? I’m so worried about my kids. Upstairs on Psych we would be wearing the negative-pressure helmet right now. Why didn’t I think to put one on here? Better yet, why wasn’t one offered to me? OK here we go…I can call and give report…”

MICU and asked if they could take the patient immediately.

Let Denise know the transfer orders had been written.

seemed distant and still upset. I asked her if I could do anything else and she just didn’t seem to want to speak to me. I’m not sure how this went so wrong but maybe it’s fear of the unknown. Down here in the ER we work in an atmosphere of complete uncertainty every day and to me this isn’t a big deal. I mean, since the start of the pandemic I have worked around lots of COVID-19 positive patients and I haven’t gotten sick. She had her mask on the whole time. I just don’t understand and this probably isn’t the right time to ask her.”

Reflection1. Comment on Denise and Jason’s interpersonal approach during this period. Does it appear they are communicating effectively? (Obj.

1)

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2. Does it appear an effective exposure control policy has been implemented? If so, how? If not, what areas for performance improvement would you suggest? (Obj. 2)

3. Do you suspect wearing the negative pressure helmet while providing 1:1 monitoring is a policy specific to the inpatient Psychiatric Unit? If so, should a similar policy be implemented hospital-wide? (Obj. 2).

Time Denise Commentary Jason Commentary2200-2300 After Denise hastily enters a

Transfer note in the EMR, Jason informs her the MICU bed is ready and that he will have Tanya, a Nursing Assistant, go with her during the transfer. Since Patient C is designated as a psychiatric patient, two police arrive and appear just a bit impatient while Denise and Tanya gather his belongings, paperwork, and instruct him to move from the gurney into a wheelchair.

Denise nods to Jason as they leave and silently walks alongside Patient C while the Tanya wheels him and the police follow behind. As they arrive at the MICU, Denise fights back tears as she again gives a brief report and hands the paperwork to the charge nurse.

The police leave and Denise tells the Tanya “Please tell

“I feel like I hardly knew this patient and now I have to put in this long Transfer Note. This charting template is almost as long as doing an admission! At least I finished it by the time MICU called with the OK to transfer. I feel like I’m just all inside myself right now. I just want to go home. I feel scared and angry, all at the same time. I also feel I have been a little unprofessional, but can anyone blame me? Jason should be ashamed of himself. I mean I know they probably work with this stuff all the time but I don’t and I think he should have been more on the ball. Everyone probably thinks I’m difficult and I really don’t care at this point. I

As this incident has occupied a good deal of his time, as soon as Denise left, he quickly checked on her other patient, his patient, and the ER’s operations in general. The ER was not very busy for the second half of the shift and there was little else going on. Jason settled in do his charting and then gave the Nursing Supervisor a ‘heads up’ on the patient going to the MICU. Just then, Denise arrived and appeared to be crying. She walked past Jason and the Supervisor, who tried to speak to her but she just kept talking and checked on her other patient. She walked to an adjacent charting area and sat down silently. Jason

“Wow I will really be glad when this shift is over. I’m just glad we weren’t very busy. Denise left to take her patient upstairs and I did what I could to get everything done before she got back. Tanya came back by herself and to be honest, I was surprised when she told me Denise was going on break. OK I get it. I understand she’s made at me about this COVID-19 positive patient, but enough is enough. It’s time to get over it. I really don’t ‘take breaks’ in the ER, and usually just end up eating at the desk. I mean, when it’s really busy we just don’t do that. Breaks are an ‘inpatient thing’ and I kinda resent her leaving me for a half hour to transfer a patient and then sending word she won’t be back for what…another half hour? Who does that, leave another nurse for a whole hour alone in the ER? When the Supervisor stopped by for their usual update I was really tempted to report her but I have always gotten along with her and decided to just let it ride. I said nothing other than we were finishing up transferring a COVID-19 positive patient to the MICU. Denise then showed up and the Supervisor looked at me like, ‘what is going on here?’ They are probably going to think I did something to her. I just can’t wait for this shift to be over.”

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Jason I’m going on a break.” Denise does not respond to Tanya’s “are you ok?” and walks in the opposite direction. She makes her way to the darkened closed cafeteria and sits at a remote table for 20 minutes and then returns to the ER. Upon her arrival, Denise finds Jason speaking with the Nursing Supervisor, who stopped by for an update. Both Jason and the Supervisor seemed surprised at Denise’s appearance and expressed their concern. Upon hearing of the dilemma, the Supervisor informs Denise she can contact Personnel Health about a COVID-19 test and offered for her to fill out an Unusual Incident Report (Exposure Incident).

really just want to go home. So I guess I’m entitled to a break, even if it’s at the end of my shift. I should have called Jason myself but at this point the Nursing Assistant can tell him. When I get back to the ER I see the Supervisor standing there and think ‘oh great, he wrote me up!’ I told them I’m fine and just want the night to be over.’ I know I will probably need to call Personnel Health and fill out more reports but for right now I’m done. I get to go home in a half hour and that’s all I have on my mind ”

watched as the Supervisor walked over and quietly spoke to her.

Time Denise Commentary Jason Commentary2300-

midnightDenise takes the phone numbers for Employee Health given by the Nursing Supervisor and puts them in her pocket. She finishes charting on her other assigned patient and then moved into action. She emptied a laundry hamper,

“I am so angry. Someone should have told me I was dealing with a COVID-19 positive patient. Policy or not, I would have insisted on wearing the negative pressure helmet so I could have

As Jason gave report to an incoming nurse, he watched as Denise left the ER. Although it has been a while since she floated, Jason remembered her as being very friendly and a great nurse. Although

“OK I know she’s mad at me, but I’m mad too. Don’t be nurse if you can’t handle a crisis. Things like this are bound to happen. I feel bad for her, but at the same time that’s not reason to be rude to me. At least say good-bye. I better leave a note for my Nurse Manager to give him a heads up about this, especially if Denise raises a ruckus. She never struck me as the fragile type. Something must

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organized the Nurses Station, and straightened a rack containing various forms. She ignored Jason when he joked ‘you are amazing. Can we hire you?’ When the incoming shift arrived, Denise quickly gave report, and left the ER without saying good bye. She returned to the inpatient unit to get her coat and car keys and left. She made it to her car and as soon as the door closed, clutched the steering wheel and wept.

cared for him and not have all this worry. I mean I pride myself on being a good nurse and I wasn’t any of those things tonight. I didn’t hardly talk to my co-worker, who I honestly blame for this whole mess. I know he works in the ER and is used to stuff like this, but I don’t and I’m not He seemed kind of arrogant and that bothered me. I’m under so much stress at home and with school right now and am I supposed to go home now and quarantine myself from my own kids? What am I going to do?”

he considered running after her to clear things up, he decided not to. He finished report and went home.

be going on with her.”

Before reviewing the following questions, please readDenise and Jason’s final reflections that follow this scenario.

Reflection1. Do you think Denise’s behavior was justified, especially from the perspective of teamwork and collaboration? If in the same situation, how would you have reacted? (Obj. 1)2. Comment on the Nursing Supervisor’s suggestion for Denise to follow up with Employee Health in the morning as well as fill out an Expose Incident Report. Given Denise’s reaction, do you think this suggestion was adequate or would you think additional action is needed? (Obj. 2 & 3)3. If you were Jason, how would you reach out to Denise, especially if you were concerned that she was stressed or upset? (Obj. 3) 4. Do you think Jason was justified in leaving a voice and emails to his supervisor? What do you think he was trying to accomplish by doing so? (Obj. 1 & 2)

Behind the Scenes: How Could This Happen?Background Prior to Denise and Jason’s Arrival

Patient C is a 28-year-old man who presented for a scheduled visit to the Primary Care Clinic (PCC) for a follow-up visit with Dr. Mack, his Primary Care Provider (PCP). Patient C was observed by the registration clerk crying and becoming increasingly despondent in the waiting room. The clerk notified Teresa, an experienced PCC RN, who pleasantly greeted Patient C and asked him to come back to the triage area where she took his vitals (heart rate=90, blood pressure 128/78, respirations=20, temperature=101.5 (oral), and oxygen saturation 98% on room air). Theresa noted Patient C’s speech pattern as very slow and deliberate and that his appearance was grossly unkempt. Noting “Major Depressive Disorder” on Patient C’s problem list, Theresa notified Dr. Mack of these apparent psychiatric symptoms. Dr. Mack invited Patient C into an exam room for further assessment.

Per the new COVID-19 workplace policy, the registration clerk, Theresa, and Dr. Mack were wearing face masks and Patient C was provided one by the registration clerk, as she observed he wasn’t wearing one. The registration clerk was surprised, as screening checkpoints were in place at all entrances to the Medical Center, meaning no one should be allowed to enter any building without wearing a mask. Upon signing into the electronic medical record and accessing Patient C’s chart, Dr. Mack immediately reviewed his vital signs and the noted Patient C exhibiting a dry cough. Dr. Mack performed and documented a COVID-19 verbal screening note, the score of which indicated further evaluation was needed.

Dr. Mack asked Patient C to wait in the exam room while he summoned the COVID-19 Screening Team, who arrived within 15 minutes and performed a ‘rapid’ COVID-19 nasal swab test. Dr. Mack asked Patient C to remain while the test was being proceeded. During the next 2 hours, Patient C slipped out of the exam room to use the restroom and then walked down the hallway to purchase a candy bar and soda from a vending machine. He encountered a Medical Assistant in the hallway and asked for directions back to his assigned exam room. Theresa noticed the encounter and escorted Patient C back to his assigned exam room, with stern instructions that he was to remain in place until advised otherwise. Theresa asked several of her co-workers to help her in monitoring the exam room door in hopes Patient C would not leave the room again.

About 2 hours later Dr. Mack’s phone rang and he listened intently while the lab clerk informed him Patient C’s COVID-19 test results were positive. The lab clerk asked Dr. Mack for his name in order to fill out a “Critical Lab Results” note in the electronic medical record (EMR) template. Dr. Mack informed Patient C of the results and advised him he would be transferred immediately to the Emergency Department for further evaluation. Dr. Mack notified the Emergency Room’s (ER) resident on call that he was sending over a patient with acute depressive symptoms who was also COVID-19 positive. Some robust discussion followed, as the Resident asserted the patient should be transferred directly to the MICU. Dr. Mack insisted the patient be transferred to the ER “in the spirit of maintaining safe outpatient operations,” advised Theresa to “get him transferred as soon as possible,” and then abruptly left to see other patients.

Upon admission to the Emergency Department (ER), patients are triaged and placed in a medical or psychiatric holding area as appropriate. Given the possibility they may be transferred to the inpatient unit when a bed becomes available, any patient placed in a psychiatric bed must first receive a rapid

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COVID-19 test with a confirmed negative result. Until the negative result is confirmed, the patient is usually kept in one of the ER’s medication isolation beds. Nevertheless, when Patient C arrived to the ER close to shift change the receiving nurse quickly placed him into one of the 6 dedicated psychiatric bed, each of which is contained in a private observation “cubicle,” or room. Since Theresa had only been in the ER once or twice before, she had little familiarity with ER operations and didn’t ask any questions. In fact, her shift was drawing to a close and after the chaotic events of today, she was very focused on simply going home.

Jason, the evening shift charge nurse, arrived for duty and was notified that 2 of the psychiatric beds are occupied and are awaiting further assessment. Both patients were being held for acute depression and suicidal ideations. The ER’s currently policies indicated that any patient placed in one of the Psychiatric holding beds must test COVID-19 negative or they should be kept on the “medical side” in isolation with a sliding glass door closed at all times until the test results are received. Seeing both doors open and no concerns communicated by the outgoing shift, Jason assumed both patients had tested COVID-19 negative and continued to listen to report. He became aware of a staff call-in and notified the Nursing Supervisor a float was needed.

Post-Scenario Character Reflections

Denise

I still can’t imagine that this has happened to me not once, but twice! Does that make me an unreasonable person, to trust in policies and procedures that are supposed to protect me from harm? I guess I now have a different perspective on Patient A on the inpatient Psych Unit. He did test negative for COVID-19 and the results were both documented and reviewed before he was approved for admission. I heard some of the providers later say that he must have “converted” to being COVID-19 positive after admission. In other words, he had been exposed to COVID-19 prior to arriving to the hospital, tested negative in the ER, and then began to develop symptoms and test positive about 10 days later on the Psych Unit. I shuddered to think all the time he was out in the common areas being mask non-compliant and in such close proximity to staff and other patients. Although it really freaks me out, I can at least intellectually understand how that happened. I don't like it at all, but at least I understand the possibilities.

On the other hand, what happened with Patient C in the ER is a whole other story. It seems like there were many opportunities for the Primary Care Clinic to communicate to the ER that he was COVID-19 positive. I think the only bit of information the ER nurse who took report focused on was that he was a Psych patient who was more than likely suicidal. On the other hand, maybe the Primary Care Nurse who called report never told them Patient C was COVID-19 positive. Who knows? The fact is by the time Patient C arrived in the ER his results were already posted in the EMR and maybe we all should have looked. I think my mistake was not following my usual practice of checking my patients’ orders in the EMR before I meet them. Had I looked in the EMR, the COVID-19 positive results would have been very obvious in the chart’s banner. I think I felt a bit out of my element in the ER and maybe just didn’t feel comfortable finding an open computer and checking out each patient’s chart. I guess I was only focused on the safety aspect of parking myself right in front of their rooms where I could closely monitor them for safety. OK I admit I should have been more assertive and asked for a computer on wheels and looked, but the point is he never should have been there in the first place. Maybe the Primary Care Clinic

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should have kept him until a MICU bed was ready and if that sounds unreasonable, he at least should have been in an ER medical isolation room with a sitter. He never should have been assigned to me without me being advised of his COVID-19 positive status.

I really feel closer to my co-worker Eric after the COVID-19 patient we encountered on the Psych Unit. Eric was so helpful and worked so closely with me and the rest of the team on the floor. He jumped right in to monitor Patient A without hesitating. In terms of Jason, I hate to say it but I hope I never have to work with him again. I guess I will have to talk to him on the phone occasionally, but I can manage that. I found him to be very nonchalant and kind of juvenile. I mean who would joke with another nurse that they may have been working around a COVID-19 positive patient and without adequate protective gear?

Since this second COVID-19 incident I find myself feeling very depressed and even more anxious. I have to say I really don’t feel in control of anything. The demands of caring for my kids, working, and going to school have taken their toll. To be honest, I just wish I could try a different career, at least until the COVID-19 epidemic is over. I guess it’s too late now, though. I’ve devoted my entire life to nursing and have taken the additional step of pursuing my advanced degree in Psychiatric-Mental Health Nursing. I’ve done some networking and if I can hang in there for another year and a half until I graduate, a really great job may be waiting for me.

In the meantime, I just feel so depressed and overwhelmed and I’m afraid that ER shift was the last straw.

Jason

The shift wasn’t the best. I admit that. I feel very bad that Denise wasn’t notified she was caring for a COVID-19 positive patient. To be honest, I think a lot of people need to share in that responsibility. I feel like trust is the foundation of any working relationship and I let her down. Working in the ER we deal with uncertainty every day so I assumed it wasn’t such a big deal, but to her it was. I tend to think that every patient I encounter may be COVID-19 positive and I conduct myself accordingly. I wear my mask, practice good hand hygiene, and try to practice social distancing to the greatest degree possible. Sometimes that’s really hard during true emergencies, but whenever possible, I try.

I didn’t mean to sound the least bit smug when I said “oops my bad…he’s positive” but I know now that wasn’t the right choice of words for her. From her perspective, I imagine she perceived that to be very insensitive. I could have said that to quite a few of my ER co-workers and we would have worked through it, but to Denise it sounded like I was joking or minimizing.

I was in charge of the ER during our shift and that meant I had to not only care for a new cardiac patient, but also be aware of everything else that was going on and not just Denise’s patient. She goes to school with one of the nurses down here who told us that Denise had dealt with a COVID-19 positive patient awhile back on inpatient Psych and I hope that experience at least partially prepared her for this experience.

When I left at the end of the shift I wondered if I should email her or something to offer to talk but I guess I sensed it was best to just leave it alone. I did leave my Nurse Manager a voice mail and an email letting him know what happened not so much for the perspective of covering my tracks, but just so that he wouldn’t be blindsided. I guess we will have to talk about how to prevent this from happening

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again. The ‘we’ in that conversation should also include the Primary Care Clinic’s staff. Maybe the need to improve is something we can all agree on, especially so this doesn’t happen again. Nothing is full-proof, but I think the important thing is to at least try to improve.

Maybe when the dust settles I will reach out to Denise to see how she is doing and also let her know of any efforts we have made to improve. She seemed pretty mad so maybe it’s best to just let it be for a while. I really don’t like to be at odds with people so I hope Denise and I can talk in the future.

In the meantime, I hope she’s ok.

Epilogue

Denise returned home following her ER shift and was up most of the night. She showered thoroughly and washed her uniform twice. The next day she chose to wear a mask at all times around her children and then asked her parents if they could take the children for a few days. Denise’s parents were supportive but heavily questioned Denise’s reasons for the request. Denise offered that a number of assignments were due for school and they seemed to accept the response.

Once she was alone, Denise felt like the walls were closing in. She had so many assignments due felt extremely overwhelmed and didn’t know where to start. Instead she laid in bed and did nothing but watch TV. She called in sick for the next 2 scheduled shifts and missed two consecutive class sessions. She eventually forced herself to go into work and did her best to act as if nothing was wrong. The next day at school her classmates noticed she was very quiet and that she had contributed nothing to their team project that was due in one week.

When Denise left the room to get her lunch, her classmates expressed their concern and wondered if they should approach her. Hannah, Denise’s classmate/colleague at work, said she noticed Denise appeared very depressed and that her grooming had deteriorated somewhat. “I know we’re all under a lot of stress, but something is really wrong with Denise. I think we should have a conversation with her and encourage her to get some help. I’ve known her for a long time and this just isn’t like her. I found this pamphlet at our employer’s website that has all sorts of mental health information for nurses. Do you think we should all look at this together and see if she takes the hint?” Tara, another classmate, offered “yes let’s say we’re looking as a possible idea for our project and see if she starts talking.” Denise returned and steadying themselves, Hannah and Tara put the pamphlet entitled “Nurse Mental Health Screening and Wellness Toolkit” on the table as Tara says “look at this… ‘Workplace Stress Caused by COVID-19 May Cause New Onset/Exacerbation of Mental Health Concerns. Please Consult the Following Screening Tool and Seek Prompt Assistance if Needed.’ What do you think about doing a project on stress in the nursing workplace brought about by COVID-19? I’ve noticed a lot of my friends and co-workers have been impacted by the stress. Denise, what do you think……?”

Post Conference Role Play (Obj. 3)Imagine you are sitting with Denise and reviewing the attached pamphlet “Nurse Mental Health Screening and Wellness Toolkit.” Break up into pairs or small groups, with one designee role playing Denise’s character while the others express their concerns and attempt to offer her supportive encouragement to seek assistance (10 minutes).

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1. What strategy did you use to broach such a sensitive subject with Denise?2. Did speaking with a ‘nurse colleague’ about the impact of COVID-19 workplace stress on their

mental health make you feel uncomfortable? If so, how?3. Did you find the resources in the attached pamphlet helpful? Did you focus mostly on the

screening information, the self-help strategies, or both? What factors guided you in your discussion?

Summary

Submitted Materials

1). Critical Reflection Journal Template2). Oops! My Bad….He’s Positive! Case study3). Nursing Self-Help Mental Health Screening and Wellness Toolkit (teaching aid)

Evaluation Description

1). Instructor feedback to students as per submitted Critical Reflection Journals 2). Informal feedback from students to faculty3). Ongoing student-faculty discussion from observations in clinical areas impacted by COVID-19

Student Reflective Journal Format At the discretion of the instructor, the following questions can be provided to students verbally, in writing, or posted as discussion questions within the course’s online learning management system.

After reading Denise and Jason’s final reflections, read, thoughtfully reflect, and answer the following:

1. Reflect on your overall experience with this COVID-19 reflective exercise as related to your own COVID-19 experience(s).

2. Do you find yourself identifying more with Denise, Jason, or both? Please provide commentary to support your answer.

3. How would you have reacted if you were Denise or Jason? What might you have done differently in either role?

4. Given the arrival of vaccines, the world is hopeful the COVID-19 pandemic will end soon. Moving forward, how may clinical scenarios similar to that experienced by Denise or Jason impact your future nursing practice?

Nursing Self-Help Mental Health Screening and Wellness Toolkit*

David Foley, PhD, MSN, RN-BC, CNE, MPASusan Painter, DNP, PMHNP-BC

*Disclaimer: the following is intended for use as a teaching aid/prop in the “Oops My Bad…He’s Positive!” teaching scenario. Although elements of the Toolkit may prove useful in real-life, it intended for educational purposes only.

Workplace Stress Caused by COVID-19 May Cause New Onset/Exacerbation of Mental Health Concerns. Please Consult the

Following Screening Tool and Seek Prompt Assistance if NeededFor Thoughts of Suicide or Self-Harm, Call 911 Immediately

Depression

Types: Persistent Depressive Disorder (PDD:

below baseline for 2 or more years Major Depressive Disorder (MDD):

acute and debilitating

Warning signs: Decreased mood Feeling Hopeless Feeling Helpless Anergia (reduced energy) Anhedonism (loss of pleasure/interest) Avolution (reduced motivation) Altered sleep patterns (too much/little) Weight gain/loss Social isolation or withdrawal Reduced resilience Difficulty concentrating Reduced academic performance Altered coping/stress management *Thoughts of self-harm

seek help immediately

Screening and Assistance

Screen and share results with a colleague or your Primary Care Provider (PCP):

Hamilton Depression Rating Scale Beck Depression Inventory PHQ-9 Screening Tool

Help for depression: Primary Care Provider Counselor Clergy Campus Student Health/Wellness

Center Academic Advisor SAMHSA Website * or

Hotline (1-800-662-HELP) Local NAMI Chapter ** NIMH ***

Again, for thoughts of self-harm (suicidal thoughts):Seek help immediately:

911 1-800-273-8255 (24hours

National Suicide Prevention Hotline)

*Substance Abuse and Mental Health Services Administration

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**National Alliance on Mental Illness***National Institute of Mental Health

Anxiety

Types: Diffuse feeling of unease

May be transient w specific focus Phobia (Test-Taking Anxiety)

Generalized Anxiety Disorder Continuous and debilitating

Panic Disorder Acute, sudden onset/debilitating

Warning signs: Feeling nervous or restless some/all of

the time Panic or feeling of impending doom Rapid breathing or heart rate Sweating Trembling Fatigue Difficulty concentrating Impaired academic performance Altered sleep patterns Gastrointestinal (GI) problems Excessive worry Avoiding social situations

Screening and Assistance

Screen and share with a colleague or your Primary Care Provider (PCP):

Hamilton Anxiety Rating Scale Generalized Anxiety Disorder Scale Panic Disorder Severity Scale Test Taking Anxiety Self-Assessment

Help for anxiety: Primary Care Provider

Rule out underlying medical cause Counselor Clergy Campus Student Health/Wellness

Center Campus Academic Services or Office of

Disability Services (Test-Taking Anxiety) Academic Advisor SAMHSA Website or

Hotline (1-800-662-HELP) Local NAMI Chapter NIMH

Sleep Disorders

Insomnia Too little sleep

Hypersomnia Too much sleep

Sleep Apnea Physiologic disturbances during

sleep

Assess your own sleep patterns: # hours of sleep per night

More than usual? Less than usual?

Quality of sleep: wake up frequently?

Screening and Assistance

Screen and share with a colleague or your Primary Care Provider (PCP):

Sleep Disorders Questionnaire STOP-BANG Questionnaire

Sleep apnea

Help for Sleep Disorders Primary Care Provider

Rule out underlying medical cause

Counselor Stress-related or emotional

cause

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Awake feeling refreshed or tire? Clergy Explore spiritual distress

Campus Student Health/Wellness Center

American Sleep Association Eating Disorders

Types: Anorexia Nervosa: drastic reduction in

eating Physical s/s:

Weight loss (less than 80% ideal body weight)

Amenorrhea (absence of menstruation)

Lanugo (fine downy body hair) Fatigue Sallow (yellow) skin Irregular heart rhythms

Emotional/Behavioral s/s: Preoccupation with weight Secretive eating behaviors Excessive exercise Use of laxatives Excessive orderliness Loose or layered clothing

Bulimia Nervosa Physical s/s

Often at ideal body weight or slightly overweight

Calloused knuckles Poor breath and/or dentition Facial/glandular swelling

Emotional/Behavioral s/s: Excessive preoccupation with

weight or body image Secretive eating or restroom

behavior Preoccupation with weight

Screening and Assistance

Self-screen and share results with a colleague or your Primary Care Provider (PCP):

Eating Disorders Examination Questionnaire (EDE-Q)

National Eating Disorders Association Screening Tool

The SCOFF Questionnaire

Help for Eating Disorders: National Eating Disorders Association NAMI NIMH Cleveland Clinic Online Resources Mayo Clinic Online Resources Primary Care Provider Determine physical impact Counselor

Emotional conflicts Clergy

Spiritual assistance Campus Student Health/Wellness

Center

Excessive eating (binging) followed by purging behaviors (usually vomiting)

Sleep Disorders Screening and Assistance

Self-screen and share results with a colleague

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Types: Insomnia Sleep Apnea Narcolepsy Restless Legs Syndrome REM Sleep Behavior Disorder

or your Primary Care Provider (PCP):

Sleep Disorders Questionnaire

Help for Sleep Disorders: Centers for Disease Control and Prevention American Sleep Association Narcolepsy Network Restless Leg Syndrome Foundation

Promote Sleep Hygiene Be consistent. Go to bed at the same time

each night and get up at the same time each morning, including on the weekends

Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature

Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom

Avoid large meals, caffeine, and alcohol before bedtime

Get some exercise. Being physically active during the day can help you fall asleep more easily at night.

Mental Health Wellness Promotion StrategiesSupport Mental Health By Addressing All Dimensions of Health

Exercise

Benefits of Exercise for Mental Health

Increased endurance and cardio fitness Improved sleep Enhanced resilience Reduced cholesterol Increased interest in sex Increased social interaction Enhanced mood Decreased fatigue

Information on Exercise and Mental Health The National Institutes of Health

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The Mayo Clinic The American Psychological

Association

Nutrition Benefits of Good Nutrition for Mental Health

Mood balance Decreased depression Anxiety control Improved sleep

Information on Nutrition and Mental Health

The Cleveland Clinic (Mood) The Mayo Clinic (Anxiety) Harvard University (Depression)

Spirituality

Benefits of Spirituality for Mental Health

Faith Peacefulness Stress reduction Connectedness Mindfulness Belonging

Information on Spirituality and Mental Health

NAMI (Religion and Spirituality) The Cleveland Clinic (Meditation) The Mayo Clinic (Scholarly article)

Stress Management/Reduction

Increased, unchecked, or improperly managed stress can lead to depression, anxiety, fatigue and exhaustion.

Stress Management/Reduction Tips

Setting boundaries and limits Asking for assistance early Leveraging all resources

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Effective time management Prayer, meditation, or other spiritual

practices Addressing nutrition, exercise and

sleep (see above!)

Additional Resources to Promote Mental Health and Wellness For thoughts of suicide or self-harm, call 911 immediately For general mental health concerns, contact:

o Your Employee Assistance Program (EAP)o The local NAMI chapter National Alliance of Mental Illness o Resources available through Substance Abuse and Mental Health

Services Administration (SAMSA) o The National Institutes for Mental Health (NIMH)

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,187,305.00 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Notes