Background: The COVID-19 pandemic has required healthcare systems to transform the delivery of care. Although the core principles of care for patients with cancer have not changed, this pandemic has led to heightened awareness concerning the fragility of patients with cancer and how healthcare systems can protect them.
Objectives: The aims were to identify and implement inpatient and ambulatory care clinical practice changes during the COVID-19 pandemic, based on defining moments and coping strategies from clinical oncology nurses, advanced practice RNs, nurse leaders, and researchers.
Methods: This article presents a Lean Six Sigma framework, accompanied by numerous rapid cycle tests of change.
Findings: The COVID-19 pandemic required clinical healthcare providers at the authors’ institution to focus on seven priority areas. Nurses tested and implemented practice changes.
Earn free contact hours: Click here to connect to the evaluation. Certified nurses can claim no more than 0.5 total ILNA points for this program. Up to 0.5 ILNA points may be applied to Oncology Nursing Practice. See www.oncc.org for complete details on certification.
The novel coronavirus was first reported in Wuhan, China, in December 2019 (World Health Organization, 2020). Since the virus was reported in the United States on January 21, 2020, there have been almost 24 million total cases and about 400,000 deaths as of this publication (Centers for Disease Control and Prevention [CDC], 2021). There is little current evidence in the oncology nursing literature to address practice changes and innovative strategies for oncology nurses who are both coping and caring during the COVID-19 pandemic (Neal et al., 2020). The revelation that COVID-19 is disproportionately affecting vulnerable populations—particularly the immunocompromised, people of color, and older adults—is of significance in the oncology setting (Shankar et al., 2020). Patients with cancer appear to be especially vulnerable to morbidities and mortality from COVID-19 (Horn & Garassino, 2021).
The acute and critical severity of COVID-19 has challenged the entire healthcare team. Concerns about staff and patient safety have been heightened. Since March 2020, more than 2,900 healthcare workers in the United States have died in the COVID-19 pandemic (Jewett et al., 2020). A reported 30% of healthcare workers with COVID-19 were asymptomatic (CDC, 2020d). Although the safety risk is real for healthcare providers, oncology nurses have demonstrated resilience in coping while caring during this pandemic.
In addition to the challenges of equipment and supply chain shortages and the physical demands of long nursing shifts, there is the task of coping with emotional and physical fatigue. The oncology nurse workforce within the Winship Cancer Institute at Emory University, a National Cancer Institute–designated comprehensive cancer center, spans six hospitals and multiple ambulatory clinics across Georgia and is aligned to achieve cancer care outcomes and high employee safety and engagement. The purpose of this article is to share care innovations and strategies implemented by oncology nurses at the Winship Cancer Institute to improve care and support nurses’ coping and resilience during the COVID-19 pandemic.
Case study methodology and the Lean Six Sigma framework were employed to test practice changes and innovations; these have proven successful in planning and organizing, as well as in improving healthcare processes to achieve desired outcomes. Six Sigma is a dual approach to efficiency through reduction of waste while focusing on consistency and quality (Pyzdek & Keller, 2018). This management framework seemed most appropriate to vet ideas and implement rapid cycle tests of change. Time was of the essence because the oncology team struggled to respond to the rapid developments and changes brought about by the COVID-19 pandemic.
The seven principles of lean development are as follows (White, 2016), with applications to the current project also noted:
• Build quality in, which includes daily huddles involving key team members and leadership to discuss quality indicators and effectiveness.
• Eliminate waste, which involves conserving personal protective equipment (PPE).
• Defer commitment (stay flexible to anticipate any changes that may supersede the original plan), collecting and analyzing information regarding any important decisions through daily huddles with clinical teams and leadership.
• Deliver fast results by quickly evaluating the effectiveness and efficiency of the tested intervention; this also avoids the tendency of the team to fall prey to analysis paralysis before implementing the rapid cycle test of change.
• Create knowledge around PPE changes and key patient treatment strategies.
• Respect people by deferring to each person’s expertise and engaging in shared decision making and transparent communication.
• Optimize the whole by leveraging the concept of systemness (striving for seamless care across multiple entities within a system to maximize best practices) in standardizing practices throughout the healthcare enterprise.
The lean value stream involved delivering safe and optimal care with minimal disruption, saving lives, and providing for employee safety.
The seven priority focus areas resulted in strategies that changed practice to improve the care of patients with cancer and support nurses during the pandemic. These seven priority focus areas were determined by clinical staff, providers, and administration and assembled in response to the pending pandemic surge that could and would affect all healthcare system operations. They were related to the need for urgent and standardized work requiring practice changes and innovative strategies. These areas were as follows: social distancing, PPE conservation, telehealth, personal safety, telecommuting, redeployment, and self-care. The strategies and results are summarized in this section and outlined in Table 1.
Clinical staff, providers, and administration faced challenges related to the implementation of social distancing guidelines and the resulting visitor restrictions. Oncology nurses partnered with the institution’s infection prevention team to determine best practices for social distancing. Staff were faced with balancing their own emotions and anxiety related to the unknowns concerning transmission of COVID-19 with those of patients who could not have family members at their side because of the new visitor restrictions (Vogler & Lightner, 2020). Early in the initial pandemic response, only essential staff were permitted in patient care areas; this has since been modified on a case-by-case basis.
The need to socially distance and limit visitors challenged the standard of patient- and family-centered care practiced at the Winship Cancer Institute. The aim was to continue to foster intentional connections with patients and demonstrate compassion, calm, and empathy while also mitigating exposure to self, team, and patients.
Human contact took on a higher level of purpose to minimize patients’ feelings of isolation and aloneness as they coped with their own illness and virus fears (Strang et al., 2020). Nurses aimed to fill the emotional void of patients with cancer who had tested negative for COVID-19 but who were hospitalized alone while receiving their first dose of chemotherapy or when their cancer had progressed. The inability of patients with cancer to have their family present in the clinic and the hospital to reduce potential exposure to COVID-19 posed social and existential consequences for dying patients and the nurses who had to adjust to a new normal (Strang et al., 2020). In the absence of family and other visitors, oncology nurses filled the gap, providing a human presence and connecting patients and their families who could not be present through the use of virtual technologies.
Personal Protective Equipment Conservation
As the supply chain for PPE became strained, it was necessary to conserve N95 respirators for clinicians directly caring for patients with COVID-19. The scarcity of PPE, PPE conservation strategies, and alternatives to masks and gowns have been well documented (Celina et al., 2020). The Occupational Safety and Health Administration (n.d.) has documented that although PPE does not remove the hazard of exposure or guarantee full protection, it does help to safeguard workers (PPE Media, n.d.).
The search for current evidence regarding the use of PPE took on a new urgency. Per the CDC’s (2020c) recommendations, cloth isolation gowns were used because they could subsequently be laundered to optimize supplies. Cloth masks, which could be washed and reused, were sewn and donated by members of the community. Aydin et al. (2020) determined that cloth face coverings with multiple layers could help to reduce droplet transmission.
The CDC’s (2020c) COVID-19 strategies and recommendations, in particular its guidance on the reuse of masks and gowns unless visibly soiled, challenged standard practices and policies related to the use of PPE. As perplexing as they were at the time, this guidance directed the practice standards that were implemented throughout the Winship Cancer Institute.
Recommendations from the CDC concerning the extended use and reuse of N95 respirators included definitions to clarify the meaning of these terms. Extended use refers to wearing the same N95 respirator for repeated close contact encounters with several patients without removing the respirator between encounters, whereas reuse refers to using the same N95 respirator for multiple encounters with patients but removing it (“doffing”) after each encounter (see Figure 1). The mask is stored in between encounters and put on again (“donning”) prior to the next encounter with a patient (CDC, 2020a). Extended use is favored over reuse because it involves less touching of the respirator and, therefore, less risk of contact transmission. N95 respirators and procedure masks were to be reused for as many as seven days, or until they became soiled or damaged (Celina et al., 2020).
At the start of the COVID-19 pandemic, the need to review with staff the proper technique for donning and doffing PPE was identified (Hegde, 2020). Nursing leadership mobilized rapidly and developed train-the-trainer sessions for safe donning and doffing. A large unfinished space in the Emory University Hospital Tower was converted to a centralized location for training staff on donning and doffing of masks, eye protection, isolation gowns, and gloves; this area also served as a site for staff in need of updated N95 respirator fit testing. An interprofessional team consisting of nurse leaders, infection preventionists, members of the direct care team, and hospital administrators facilitated training sessions. Hundreds of nurses, nurse technicians, other direct care providers, and ancillary staff attended the sessions and completed return demonstration on donning and doffing PPE. Charge nurses and unit champions were tasked with verifying PPE competency on their home units. Unit leadership ensured that all staff in their areas had received training.
Although the health system had already embraced the use of telehealth, it was not widely used prior to the COVID-19 pandemic and was not a standard of practice in oncology clinics. Routine clinic visits and elective surgeries were deferred at the peak of the pandemic; however, patients still needed to be evaluated and monitored.
Telehealth addressed several needs during the COVID-19 pandemic, including the provision of care for low-acuity patients who did not require in-person visits, reduction of human exposure for healthcare workers and patients, reduction of in-person clinic visits for patients with chronic illnesses, and conservation of medical supplies (Rockwell & Gilroy, 2020). The oncology team averages between 110 and 150 telehealth visits per day during the COVID-19 pandemic, representing a more than 100% increase from before the pandemic.
Changes to provider reimbursement for telehealth have been additional positive outcomes of the pandemic response. The Centers for Medicare and Medicaid Services issued new temporary guidelines to increase access to telehealth services, including for those who are enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program. Additional changes include the ability for providers to conduct telehealth services with patients in their homes and outside of designated rural areas; to practice remote care via telehealth, even across state lines; to deliver care to established and new patients via telehealth; and to bill for telehealth services as if provided in person (Centers for Medicare and Medicaid Services, 2020; Health Resources and Services Administration, 2020a).
As the first cases of COVID-19 were identified within Emory Healthcare, nurses began to experience anxiety and fear related to exposing their family, neighbors, and friends to the virus; similar feelings were also reported by nurses across the United States (Heinzerling et al., 2020).
In August 2020, The Atlanta Journal-Constitution reported that nearly 100 Georgia healthcare workers had died from COVID-19 since March of that year (Judd, 2020). Nurses reported witnessing coworkers being diagnosed with COVID-19, and concerns about personal safety and inadvertently transmitting the virus to family members, patients with cancer, and others were ever present.
In a statewide survey conducted by the Georgia Nurses Association (2020), the 211 nurse respondents reported that their most notable concerns during the COVID-19 pandemic were lack of appropriate PPE and staffing workload. Sixty-nine percent of respondents said that they did not feel safe and equipped to perform their duties by following their institution’s COVID-19 preparedness plans or procedures. In the same survey, 55% of respondents said that their organization provided sufficient and timely information about COVID-19 and their role in care and safety. Open-ended comments included worries about personal and family safety, as well as long work hours and staffing concerns (Georgia Nurses Association, 2020). Similarly, the American Nurses Association (2020b) found in its survey of 21,000 U.S. nurses that 42% reported experiencing widespread or intermittent PPE shortages. In addition, 53% of nurses reported that reusing and decontaminating masks made them feel unsafe (American Nurses Association, 2020b).
In a study by Chia et al. (2020), surface sampling revealed that high-touch surfaces were associated with nasopharyngeal viral loads and peaked at day four or five of symptoms. Best practices on the nursing units at the Winship Cancer Institute included frequently disinfecting high-touch work surfaces, like counters, telephones, IV pumps, and patient bed rails; adhering strictly to PPE guidelines; maintaining social distancing at patient care team stations and in staff lounges; and following the daily staff symptom and temperature screening protocol.
Telecommuting is a formal arrangement between the employer and the employee permitting remote work (Allen et al., 2015) Emory Healthcare adopted telecommuting in March 2020 as a best practice for many ambulatory care services, affecting oncology nurse coordinators and navigators, as well as call center nurses. This practice was not common prior to the COVID-19 pandemic. The institution’s department of human resources communicated guidelines to leadership across all departments at every level to help them stay connected to their employees while working from home, including by scheduling weekly check-ins, setting clear expectations, and ensuring that employees had the appropriate technology to maintain productivity and efficiency.
The decision to bring employees back on site was driven by safety, with the key criterion being a low COVID-19 positivity rate within the healthcare system. A long-term best practice that is likely to emerge from the COVID-19 pandemic is more intentional decision making about which meetings and tasks truly need to be performed in person and which can take place in a virtual format. Employers realized financial savings by broadly employing this work model, which could mean increased productivity, improved employee morale, improved quality of work, and savings related to the workplace and utilities. In principle, less commuting also means ecofriendly reduction of gas emissions, promoting clean air (O’Brien & Aliabadi, 2020)
In the early stages of the pandemic surge, elective procedures and surgeries were canceled in an effort to create space for COVID-19 patients. Some patients avoided seeking medical care because of a fear of contracting the virus. These two actions led to an overall decrease in census and visits in ambulatory and inpatient oncology areas at the authors’ institution. Oncology nurses were redeployed to medical-surgical areas, as well as intensive care units if they had previous experience in that area. A key best practice that developed during this time was increased partnership between critical and acute care areas. Unit leaders partnered to arrange shadow experiences for acute care nurses, which allowed them to spend time on intensive care units learning more about critical care and determining how they could best assist during a COVID-19 surge. Many acute care nurses reported satisfaction with these experiences.
Some oncology nurses volunteered to work on COVID-19 units. In some instances, oncology nurses were assigned to a COVID-19 unit (or to individuals under investigation, referring to patients who were negative for COVID-19 but still had symptoms) for one shift and were back to working with patients with cancer the next day. Highly skilled nurses were approached and asked about their willingness to serve in this capacity, and the positive response was overwhelming (Martland et al., 2020).
During periods of low COVID-19 cases, the healthcare system began to resume some services that had been postponed, including procedures and surgeries. Patients undergoing a procedure are required to obtain a COVID-19 test 48–72 hours before their scheduled procedure; the test must be negative for them to proceed. COVID-19 tests are offered at several locations throughout the healthcare system, and a call team was established to notify patients of the results within 24 hours of their release by the laboratory.
Even in the best of times, caring for patients with cancer can be emotionally taxing. During the COVID-19 pandemic, healthcare providers are facing a lethal virus, a shortage of PPE, rapid changes in practice and policy, and a lack of evidence-based treatment for the virus (Rangachari & Woods, 2020).
Helping oncology nurses cope by building resilience through spiritual health, mindfulness, and meditation and by accessing the many support resources for staff made a difference in the ability of oncology nurses to cope during the pandemic. Although nurses may have their own strategies to support resilience and coping, it is sometimes helpful for nurses to be reminded to take care of themselves (American Nurses Association, 2020a).
Taking time out to reflect and regroup—emotionally, spiritually, and physically—became crucial. The Oncology Nursing Society (2020) has compiled numerous self-care resources, including activities, learning tools, articles, and various COVID-19 resources, into its Nursing Self-Care Learning Library. Best practices identified at the authors’ institution concerning self-care and resilience include debriefing after particularly challenging patient situations, allowing staff time off to tend to their personal needs, and giving team members the opportunity to ask questions and share concerns during shift change huddle, staff meetings, and hospital town halls.
This article outlines seven priority focus areas that required agile, innovative changes in practice to support the outcomes of patients with cancer, provider safety, and coping during a novel pandemic. The Lean Six Sigma framework can be used to look at opportunities that may improve efficiencies in care practices and procedures, and optimize quality and safety initiatives for patients and members of the healthcare team. The willingness of institutional leadership to engage all stakeholders in developing novel solutions during a pandemic was key to success. The entire oncology healthcare team of nurses, doctors, advanced practice providers, and administrative leaders came together to develop, implement, and support practice changes to meet the needs of patients, their family members, and staff during the COVID-19 pandemic.
Some of the best practices that emerged during this time are likely to be carried forward into the future; these include having an increased focus on a clean and safe work environment, leveraging technology to conduct work and meetings virtually when possible, serving as good stewards of resources by minimizing waste, and leaning in even further to compassion and kindness during challenging times. Oncology nurses continue to meet the challenge of the COVID-19 pandemic by keeping patients safe while delivering optimal care and supporting team safety. Some of the strategies and practice changes implemented during the pandemic may be applicable to other patient care areas as the experiential evidence mounts alongside the scientific evidence, which does not yet exist in many of these priority areas. To prepare for the next pandemic, health systems can now refer to data and experiences from the COVID-19 pandemic. Administrative and clinical teams must be vigilant in their response to new and revised guidelines, which will evolve from this pandemic.
As new evidence and guidelines emerge concerning the novel coronavirus and clinical care of patients, oncology nurses must be nimble and flexible. Process changes have occurred since the start of the pandemic. For example, for the first several months, only patients with symptoms were tested for the virus at Emory Healthcare. As testing capability expanded and cases began surging in the metro Atlanta area, testing began for all newly admitted patients. In addition, there is an increased emphasis on eye protection when caring for all patients, not just those with suspected or confirmed COVID-19. Based on updated information, oncology nurses throughout the organization have demonstrated competencies that allow them to revise their clinical practice. As more is discovered about the novel coronavirus, additional change will be required.
The success of these innovations and practice changes at the Winship Cancer Institute is highly dependent on the collaboration and support of the entire team of oncology nurses, providers, and administrators. This pandemic response called for engagement of all team members to develop and support solutions to meet the needs of all oncology healthcare team members.
Ongoing process changes have occurred in response to new guidelines and information made available during the pandemic. Oncology nurses throughout the organization have demonstrated a remarkable ability to shift their practice based on updated information.
During the COVID-19 pandemic, there has been considerable public acknowledgment of the significant role played by healthcare providers, particularly nurses, who are being recognized as the lifeline of patient care, shaped and molded by compassion and dedication to duty of care over fear (Romano, 2020). Throughout the COVID-19 pandemic, oncology nurses—as valuable members of the interprofessional team—have been visible in their contributions, resilience, critical lifesaving skills, and care (Rowley, 2020).
Experiences from this pandemic allow oncology nurses and leaders to improve pathways to deliver clinical care. Oncology nurses at the authors’ institution have reported that they have sharpened their coping and resilience skills, which have helped them focus on care to overcome their fears during the COVID-19 pandemic. There will continue to be novel innovations, interprofessional respect, and collaboration in oncology practice that will likely allow healthcare providers and teams to emerge stronger and wiser, resulting in better and sustained outcomes for patients and healthcare providers in the post–COVID-19 era.
The authors gratefully acknowledge Sharon Pappas, PhD, NEA-BC, FAAN, for her system leadership; Kari Love, RN, MS, CIC, FAPIC, for her review of the article related to infectious disease guidance; and Felicia Williams, DNP, AOCNP®, for her input into the use of telemedicine in the ambulatory oncology clinic.
About the Author(s)
Regina Duncan, BSN, RN, OCN®, CNML, is a unit director on the inpatient oncology unit at Emory Decatur Hospital; Brittany Szabo, MSN, RN, MBA, OCN®, is a unit director and Quincy L. Jackson, MSN, RN, is a senior nurse manager, both at the Winship Cancer Institute at Emory Saint Joseph’s Hospital; Maria Crain, BSN, RN, BMTCN®, is a unit nurse educator at Emory University Hospital; Celia Lett, FNP-BC, AOCNP®, is an oncology and nononcology infusion center advanced practice provider at the Winship Cancer Institute at Emory University; Connie Masters, MSN, RN, MBA, OCN®, is a specialty director of oncology at the Winship Cancer Institute at Emory Saint Joseph’s Hospital; Renee Spinks, MSN, RN, ACNS-BC, AOCNS®, is the director of patient care in oncology, surgery, and transplant services at Emory University Hospital; Lana K. Uhrig, PhD, MBA, RN, is the vice president of cancer nursing services at the Winship Cancer Institute at Emory University; and Mary M. Gullatte, PhD, RN, ANP-BC, AOCN®, LSSYB, FAAN, is the corporate director of evidence-based practice and research at Emory Healthcare, all in Atlanta, GA. The authors take full responsibility for this content. Gullatte received a grant from the National Cancer Institute for unrelated research, is a board member for the Nurses Service Organization, and has been an independent consultant for the Branden Corp. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Gullatte can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted July 2020. Accepted October 13, 2020.)
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