The care of patients through the lens of the fundamentals into times of the COVID-19 outbreak

Dear Editor,

SARS-CoV-2, responsible for the consequent infection named coronavirus disease 2019 (COVID‐19), has to date 2,245,872 cases and 152,707 deaths within 213 countries, correct for the 19th April 2020 (WHO, 2020). Certain peculiarities in the care of patients with COVID‐19 differing from the usual nursing care have emerged from our experience as nurse educators who are usually working in the University but have returned to the bedside in the intensive care unit (ICU) during the Italian outbreak.

Following the Fundamentals of Care framework (Feo et al., 2018), those elements listed under the ‘physical’ area constitute the primary needs of a patient with COVID-19. The clinical presentation of these patients ranges from a mild upper respiratory tract infection to a severe acute respiratory distress syndrome (Huang et al., 2020), therefore airway and breathing management is the main concern. Subsequently, clinical management, such as oxygen, antiviral drugs, antibiotic prophylaxis, invasive and non‐invasive ventilation, patient positioning, as well as all safety procedures for the infection control (Sorbello et al., 2020, Jansson et al., 2020) are fully addressed. Unfortunately, ensuring toileting needs and personal cleansing (e.g., mouth care), that have been both reported to be delayed or missed in ‘normal’ times (Richards et al., 2018), appear to be more at risk to be omitted due to the patient’s acute illness and the increased nursing workload and shortage of nurses (Giusti, 2020). Alongside these needs, other concerns regarding surveillance are emerging, as in the case of pressure ulcer risk in patients in the prone position or with a prolonged use of non-invasive ventilation devices. Moreover, some medical treatments, such as administration of continuous positive airway pressure, may hinder patients’ needs such as eating and drinking or patient comfort, as the nurse may not be immediately available to provide for these needs. Similarly, promoting adequate rest and sleep is also challenging in the overwhelmed wards struggling with COVID-19 (Sorbello et al., 2020).

With regard to ‘psychosocial’ care, communicating with these patients has its own challenges. Nurses must protect themselves from the airborne pathogen, requiring masks, goggles and/or face shields (Jansson et al., 2020); this prevents the nurse from speaking normally and being close to the patients for a long time. Moreover, personal protective equipment creates additional barriers to communication and reduces the opportunity to identify and discern the health professionals’ role. In the COVID-19 wards, confidentiality and privacy may always not be respected. In the effort to admit newly infected patients, nurses attempt to create an environment capable of offering more beds than the hospital is used to providing, thus generating unavoidably overcrowded rooms. As nurses are following strict safety protocols and procedures, patients’ interests (e.g., move freely around the wards) and priorities (e.g., keeping and using personal possessions) are at risk not to be considered and accommodated; this is a situation that may leave patients’ psychological needs compromised.

Regarding the ‘relational’ dimension, family members are not allowed to visit their loved ones, as with the reduction in nurse staffing and physical space it is too complicated to support, involve and protect families; therefore the only contact takes place daily via telephone to update the medical reports. The nurse is then left with the issue of how to help the patient cope and stay calm. For example, some patients are able to receive information using mobile phones, tablets and computers, however these resources are currently scarce and not available to all patients. Even if this is available, the news is far from reassuring reporting alarming information such as daily deaths and numbers of new cases. As a consequence, feelings of helplessness and stigma, as well as higher levels of stress and anxiety among hospitalised patients may emerge (Wang et al., 2020). Therefore, emotional and social support has to be considered among both the short and the long-term goals to improve psychological resilience during the COVID-19 epidemic, especially among older people. Lastly, we have to consider the right to die with dignity in this pandemic era (Pattison, 2020): in the dying phase, no family can see their loved one, as rigorous measures have to be carried out due to orders to avoid physical contact.

Nurses are changing rapidly their patterns of care by prioritising some of these to ensure the patients’ needs; however, some fundamental needs may be omitted. We do not know how long it might take to overcome this health emergency, however by reflecting and learning in depth from this experience, nurses will get back to the ‘normality’ definitely more prepared to deal with future challenges.