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Strength, resilience, and innovation

Strength, resilience, and innovation

Acute care nursing during the pandemic

The stress and trauma of COVID-19 affected everyone, and acute care nurses have felt more than their share. They serve on the front lines and at the center of the pandemic, and many say the difficult experiences of the past months make them stronger and even more committed to nursing. 

Throughout this historic period, Cizik School of Nursing at UTHealth faculty members have tested innovations, graduates have led practice improvements, and students have provided compassionate care at the bedsides of critically ill patients.
 

Nurse practitioners

Many students seeking Master of Science in Nursing degrees to become nurse practitioners (NPs) – like Roxanne Mana-Ay, BSN, CCRN, and Christopher Falgout, BSN, RN – are already experienced nurses who continued working during the pandemic while taking classes that shifted online. 

“We’ve learned that our students and alumni are very resilient, and so are the faculty,” said Lori Hull-Grommesh, DNP, RN, NEA-BC, FAANP, describing virtual simulations and other innovations quickly implemented to ensure students could meet clinical requirements and other program goals. An assistant professor in Cizik School of Nursing’s Department of Graduate Studies, Hull-Grommesh serves as the interim track coordinator of the acute care/gerontology NP track. She teaches future NPs alongside assistant professors Tammy L. Stout, DNP, RN, ACNP-BC; Seth Stephens, DNP, RN, ACNP-BC, CPHQ; and Tonya Page, DNP, RN, ACNP-BC.

 

Hospital leadership

Cizik School of Nursing alumna Betty Gonzales, DNP, RN, ACNP-BC, CCRN, serves as director of nurse practitioner services at a hospital in Fort Bend County, where the state’s first documented case of COVID-19 was diagnosed in early March 2020. 

“We got our first patient here, I believe it was March 6,” recalls Gonzales, who directs 24 NPs at Houston Methodist Sugar Land Hospital. “During our first spike in March of 2020, we thought that was as terrible as it could be, but that wasn’t nearly as bad as July.” 

The NPs interviewed throughout the Houston area agreed that the July surge was in some ways worse for them than the larger winter peak because they knew much less in the summer about COVID-19. 

“There was no book to go by on how to treat these patients,” Gonzales noted. 

To help keep everyone at her hospital up to date on the rapidly changing guidance and developments, Gonzales organized a standing interprofessional conference on Friday afternoons that brought together intensivists, pulmonologists, pharmacists, and other clinicians to discuss the latest treatment information and share their own experiences. She said Cizik School of Nursing’s doctor of nursing practice program helped give her the confidence to take on a leadership role and work with physicians and administrators toward innovations.
 

Taking its toll

Mana-Ay has plenty of experience working in intensive care units (ICUs). Shortly before the pandemic began, she moved into the “flip pool,” meaning she worked in various types of acute care units throughout her hospital. 

Her work on high-acuity units means losing a patient is not uncommon. However, she noted the number of deaths due to respiratory failure increased dramatically as the pandemic began. 

“We are trained to deal with death as nurses. It is our job to provide patients a comfortable environment and protect their dignity as a person,” Mana-Ay said. “The amount of death was taking an emotional toll on all of us.” 

Mana-Ay’s most difficult and most hopeful moments both involved terminally ill patients – the first a young patient whose health declined rapidly and unexpectedly, and the second an older patient who roused from an unresponsive state to witness a family milestone via video chat. 

“Prior to COVID, I knew that the profession was about caring for patients and being an advocate for them, but with COVID, it transcended that principle. With our patients dying without being able to see their family members, the nurses have really taken the initiative in setting up online visits and communicating with families to alleviate their fears and stress,” Mana-Ay said. 

“It’s very daunting and heavy, and emotionally you are drained before you even walk into a patient’s room,” Page said, describing the layers of protective clothing and gear required in the ICUs, long ventilator tubes running outside of rooms, and the inability to touch and comfort patients. 

Falgout, who works in the cardiovascular (CV) ICU at Houston Methodist Hospital in the Texas Medical Center, has specialized training to operate some of the equipment used for some of the sickest COVID-19 patients, such as extracorporeal membrane oxygenation (ECMO) machines. 

Most days, Falgout worked in the CV ICU unit as he normally would. However, he treated COVID-negative patients with a greater variety of conditions as the regular ICUs became COVID units. But like everyone else, he cycled through the COVID ICUs during the summer peak. 

“I feel like our unit was spared quite a lot of the trauma that the other units experienced. You feel kind of guilty because of that,” Falgout said. He would check his assignment each morning, anxious that he might have to report to a COVID unit. 

As a manager, one of Gonzales’ most difficult tasks during the pandemic was helping staff members overcome their understandable and palatable fears. In many cases, nurses with personal situations that could have exempted them from working during the pandemic – young children or immunocompromised relatives at home, or even their own pregnancies – continued to show up every day. 

“I felt like I was never at home. They just kept coming and coming through the ER,” Gonzales said. “I’ve been doing this a very long time, and this is the saddest thing I’ve ever seen.” 

Mana-Ay said she appreciated the spiritual support line that Houston Methodist provided where employees could call when they felt overwhelmed.
 

The good from the bad

All agreed that sharing experiences with other health care professionals in similar situations helped, and that the pandemic has strengthened individual nurses, nursing teams, and interprofessional bonds. 

Innovations in technology and teaching practices born of necessity during the pandemic will likely benefit students, nurses, and patients of the future. Erin Cusack, director of government affairs for the Texas Nurse Practitioners Association, also hopes the experience will someday help state lawmakers recognize the value of removing regulatory barriers that would expand NPs’ ability to provide care. 

In Texas, an NP must have a delegation agreement in place with a physician in order to practice. Traditionally, these agreements have been one-to-one contracts between physicians and NPs. The pandemic, however, called for more flexible and efficient approaches, including broader agreements with hospital systems. However, the 2021 biennial session of the Texas Legislature ended without extension of temporary measure that waived the requirement for these delegation contracts. 

While vaccines have enabled nurses to breathe sighs of relief and hope, they recognize that the pandemic is not over. In fact, they all mentioned that the patients they have treated more recently tend to be younger. But with a better understanding of the disease, effective treatments, and more than a year of experience treating patients with COVID-19, they feel a bit more optimistic about outcomes. 

“This is a piece of history that I want to be part of,” Gonzales said. “I didn’t do it for my kids to say I was a hero. This is what I do for a living. This is where I should be, and I was honored to do this.”

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Dr. Betty Gonzales
Cizik School of Nursing alumna Betty Gonzales, DNP, RN, ACNP-BC, CCRN, serves as director of nurse practitioner services at Houston Methodist Sugar Land Hospital.