Orthopaedic nursing and the COVID19 pandemic: the first few months.

At the time of writing (early June 2020), the COVID19 pandemic has affected almost every aspect of life in every part of the globe. This frightening disease has devastated families, communities, and society. Despite this, the hard work and astounding adaptability of healthcare organisations and their staff has been making headlines everywhere. The planning, alterations to existing systems, new rules and guidelines and managing staff and patient expectations has created significant pressure and stress at all levels. The exisiting shortages of nurses and variations in nurses’ working conditions in some countries forms the background to this significant increase in activity. The global economic impact of the pandemic will ultimately lead to a deeper fiscal crisis in many economies that will place additional pressure on future resourcing of healthcare and, perhaps, motivate governments to rethink how healthcare is funded.

At the very beginning of this ‘World Health Organization Year of the Nurse’ we could not have known just how much nurses would be given the opportunity to demonstrate their worth in every corner of the globe and in every healthcare setting. Nurses are at the hub of global, national, and local responses to COVID19. The impact of the pandemic on the profession, individual nurses, and the communities they serve will be documented in nursing and healthcare history. Coping with day to day practice in this acute, intensive period of activity has needed great resilience as nurses have had to try to prepare for the unknown and for what might and might not be to come – along with not knowing when it will be over. Maintaining this resilience in the coming months will be a part of the story we have yet to experience or understand.

Nurses (averaging around 60% of the health care workforce) have, over the months since the pandemic began, been focusing on supporting individuals and their families in preventing and recovering from this dangerous and unpredictable viral infection. They have also been caring for those who are dying, have died, or are grieving following the death of loved ones while families have often not been able to be present at a loved one's death. The central role of nurses in the care of patients who are critically ill or at the end of life with COVID19 has meant that they have often been the only person present at death, feeling the weight of spiritual responsibility.

Media reports suggest that communities are acutely aware of how much nurses are contributing to the COVID19 efforts, despite the well-publicised shortage of nurses and challenges in nursing education, recruitment, and retention in many parts the world. During such an unprecedented event there are ongoing pressures in accessing suitable resources such as appropriate personal protective equipment (PPE) and virus and antibody testing. Media reports from some countries suggest that many nurses have faced difficulties and risk to their own health and that of their patients because of inadequate availability of PPE in the early months of the pandemic.

Nurses have demonstrated outstanding adaptability and willingness to innovate in the way they have changed and developed their roles in the early stages of the pandemic. Orthopaedic nurses have, of course, been very much part of the nursing response to these unprecedented challenges and will be an important part of continuing efforts to control the spread of the virus, save lives and, eventually, return healthcare services to some normality. Simply continuing to meet the everyday ongoing needs of other patients who have suffered falls and fractures, for example, while also continuing to manage planning and care for COVID19 is an enormous task, and one unlikely to be obvious to the general public. It is also evident, however, that despite the perception that many patients avoided presenting to hospitals due to illness or injury because of the COVID19 pandemic, the number of orthopaedic patients presenting with fragility fractures has remained constant in many countries. The true effect of isolating older and vulnerable members of society remains to be seen with an expected increase in the number of falls and injuries at home anticipated over the weeks and months ahead. Elective work may have largely ceased during this period, but trauma remains a constant presence and the ability of nurses to adapt treatment pathways to screen patients for COVID19, manage new operating theatre arrangements, ward arrangements and discharge pathways within the confines of the pandemic-affected world has been a challenge like no other on such a global scale.

Re-deployment has been especially common in orthopaedic units in some areas, enabling hospitals to focus resources on managing COVID19 demands. Many orthopaedic and trauma outpatient clinics have been cancelled due to redeployment of staff, difficulties in managing social distancing in clinic settings, and because some patients are reluctant to attend hospitals as they are fearful of the risks of infection there. Some healthcare providers already have well established systems for virtual/non-face-to-face orthopaedic follow-up services using telephone or video conferencing. For others this is a new way of working that requires nurses and other members of the team to develop assessment and clinical decision-making skills in a different context. The shift from face-to-face consultations to virtual approaches is likely to be a more permanent feature of healthcare provision in the future. Social distancing measures will be in place for the foreseeable future and this will require orthopaedic teams to develop new ways of working and supporting patients to engage effectively in virtual methods of clinical consultation.

Re-deployment has also involved a great deal of learning on the job as demands change from hour to hour and week to week. Nurses have been reorganising their units to open more beds for patients with COVID19, while keeping other patients safe. They have also been taking stock of equipment and ensuring efficiency of its availability to the right staff member or patient at the right time. Being re-deployed to an area in which a nurse is not an expert, for example an experienced orthopaedic nurse working in a unit for patients with COVID-19, is stressful. Nurses must work within the scope of their professional knowledge and skills, acknowledging any deficits that require training, induction, and mentoring. This requires a supportive working culture and strong nursing leadership. The lessons learned from these experiences may, of course, have a significant positive impact on practice.

The postponement of elective orthopaedic procedures and ongoing restricted access to medical facilities have left many patients continuing to suffer with significant pain, limited mobility and anxiety while facing a long wait for assessment and their surgery in this period. At some point, health services will need to “catch up”. In the meantime, it is important that individuals are supported with symptom management options and reassurance, either through their primary care providers and/or advisory helplines from orthopaedic services. As the pandemic stabilises, in those places where elective orthopaedic surgery has been postponed, there will be unprecedented numbers of patients needing to engage and re-engage with orthopaedic and trauma services and this will require significant planning.

The significant contribution of orthopaedic nurses globally, has meant that they have already faced extreme challenges in their everyday working lives. They have done this with commitment and compassion. The International Collaboration of Orthopaedic Nursing (ICON) which represents orthopaedic nursing associations from 14 countries has come together virtually to share the experience and learning from each country as we all face this pandemic at varying stages. The potential of virtual sharing and reaching out to each other has never been more important and offers some positive opportunities for the global community of orthopaedic nurses to collaborate. Many organisations are working on ways to bring nurses together using communication technology to enable virtual conferences and meetings. The most important message is to know that we are all in this together and that there is always someone you can help or who can help you.

The team at the International Journal of Orthopaedic and Trauma Nursing wish to acknowledge the immense contribution their colleagues are making to the effort to control and manage COVID19 across the globe while continuing to provide essential orthopaedic and trauma care in exceptional circumstances. This topic will stay with us for many years to come and we will return to these issues often as the situation progresses.