Tallaght University Hospital, submission to Covid-19 Evaluation
Introduction
This submission has been developed on behalf of Tallaght University Hospital by Cesira McCrohan, End of Life Care Coordinator, with the assistance of John Kelly, Director of Pastoral Care and Ann Hickey, Assistant Director of Nursing who was the End of Life Care Coordinator during the Covid19 Pandemic.
As is widely acknowledged the Covid 19 pandemic was a very frightening experience for many – it was a time filled with so much fear and uncertainty. It challenged people, organisations and the nation as a whole in so many ways. So much was demanded of those working in healthcare and for those receiving care in healthcare facilities it was often a terrifying experience. Healthcare staff and others often went above and beyond what was expected of them. While there are many, many heartrending stories there are also many stories of kindness and compassion too.
In response to the rapidly changing healthcare environment Tallaght University Hospital (TUH), like other healthcare providers, had to adapt to the rapidly changing situation which involved changing practices in an effort to protect patients, staff and the public. Policies and procedures were developed and frequently revised as new information became available, in accordance with direction given by the HSE, government agencies and local governing structures, including the executive management team and infection prevention & control department.
Practices were changed and new initiatives evolved in an effort to make a very frightening situation a little better. Throughout the pandemic the importance of human presence when people are sick, lonely or frightened was highlighted however sometimes the circumstances made it impossible to achieve this goal.
As TUH participates in the Irish Hospice Foundation Hospice Friendly Hospitals (HFH) programme, the organisation always tries to ensure that compassionate end-of-life, palliative, and bereavement care is central to the work of the organisation. The experience of the pandemic has had a lasting effect on patients who survived, families of those who were sick or have died during the pandemic.
Many staff experienced significant personal trauma due to the limitations that the national guidance imposed on them in relation to the care that they were permitted to give to their very ill and dying patients. Staff often went to great lengths to ensure the experience for all patients was the best it could be despite the restrictions.
Many patients and their families had positive experiences during the pandemic and have recounted the kindness and compassion shown by the staff caring for them.
What were the challenges?
One of the many challenges of the Covid 19 was wearing Personal Protective Equipment (PPE) for long periods of time. At the outset the shortage of PPE was an issue but this was resolved quickly once an understanding of requirements was established. Wearing PPE for long periods was very difficult and exhausting which made an already stressful environment even harder. Patients were often fearful of seeing staff dressed as ‘aliens’. Many people are still disturbed by the amount of waste generated by single use, non-recyclable items and equipment used in healthcare during and subsequent to the pandemic.
Communication was very difficult when wearing masks and visors, especially for those who had impaired hearing or other communication needs. The use of ‘see through ‘masks where the wearer’s mouth could be seen would have improved communication.
Visiting time limitations were imposed to reduce the risk of exposure to the virus and were only permitted in EOL situations. This limitation was very difficult for all involved, especially the family members who had to leave their dying relative after 15 / 20 minutes. An attempt was made by the hospital to reduce any distress by facilitating escorted visiting for relatives of acutely ill or dying patients. The visitors were met by a staff member at the hospital entrance, shown how to wear PPE correctly and were brought to see the patient. The staff member offered emotional support to the visitor following the visit.
While all other patients were not permitted to have visitors during the pandemic the effects of this separation was minimised by making IPads available on the wards for patients to contact their loved ones.
Another example of a thoughtful gesture to relieve distress on families were the knitted hearts made by volunteers in the community. These knitted hearts which were distributed by the Pastoral Care Team to dying patients and their family. One knitted heart remained with the patient while others were given to family members to keep as a cherished link of their deceased loved one.
An initiative to support staff at this time were the designated Breakout Rooms which were created, furnished and decorated to create quiet spaces for staff meal breaks while maintaining social distance. Additional spaces, such as the family rooms on wards, normally used for EOLC situations or for care planning meetings were used to provide spaces where staff could rest.
The hospital was very aware of the effects that lack of contact can have on patients and family alike and wanted to enhance the patient’s experience of being in hospital. Initiatives such as the patient parcel drop off and collection points in the main foyer, the delivery of emails and letters to patients by the Patient Advocacy and Liaison staff, and the creation of information booklets to keep people informed are just some examples of ways that the organisation assisted patients and families remain connected during the pandemic.
Bereavement Supports
Bereavement can begin before a person dies and can last for an indeterminate time following a death or loss. Grief and bereavement can have a lasting effect on a person’s health, relationships and their ability to contribute to society or to return to work and can lead to increased demand on health and social services. Good bereavement supports in the acute setting which are continued in the community setting can mitigate the long term effects of grief. These bereavement supports, e.g. access to professionals trained to give bereavement support, were inadequate prior to, during and following the pandemic, however due to the lessons learned from the pandemic they should be given greater priority and properly resourced. Community based and charitable organisations often provide support in the community but these are underfunded and access to these services varies throughout Ireland.
Due to the experience of the pandemic it was recognised that while there was a bereavement support network for the North Side of Dublin there was a lack of similar bereavement support network for the South side of Dublin. In collaboration with the IHF and EOLC in TUH, Ann Hickey, the South Dublin Bereavement Network (SDBN) was created. The SDBN is a thriving source of support for people on their bereavement journey. The SDBN also provides networking opportunities and education for service providers.
In addition to the daily chaplaincy work the Pastoral Care Team continue to support bereaved families and staff through the annual services of remembrance held in the Hospital Chapel which gives comfort to many families. The significance of contact post bereavement was highlighted by feedback from families who appreciate the sympathy card, designed within TUH during the pandemic, which is sent by the Pastoral Care Team and by some wards, to each family following a death.
Fear:
Everyone was fearful of this new virus, of getting it but also of spreading it to others and family members. Staff were very meticulous about hand hygiene, their own personal hygiene practices, often going to great lengths to minimise the risk of transfer of the virus to others outside the hospital. Many even stayed away from their families for long periods of time in an effort to protect them and often worked longer shifts to provide continuity of care and to support each other.
The feeling of fear and uncertainty due to this new experience added to the levels of stress and distress experienced by staff. Some patients, members of the public and staff were strong in their resistance to accept the facts of the pandemic and the restrictions imposed on their lives.
Even today, staff are still affected by their experience during the pandemic, including student nurses, doctors and health and social care professionals whose training was interrupted or changed. Facilitated reflective sessions where staff were encouraged to share their experiences in a safe and supported way to promote healing were offered to all staff in the months following the pandemic. Many staff found them to be beneficial and others have found other ways to process their experience of the pandemic. Since the pandemic there is an increased emphasis on well-being with many practicing techniques, such as mindfulness / breathing exercise which they learned during the pandemic, on a daily basis.
Preparing Health Care Workers to give excellent, person centred and compassionate End of Life Care
To ensure that all healthcare workers are equipped with the skills and knowledge to deliver excellent, person centred and compassionateEOLC we recommend that all TUH staff, including all clinical, non-clinical staff and volunteers, attend education / training in End of Life Care appropriate to their role or department. The training offered includes the ‘Final Journeys’ workshop, ‘Practical Language and phrases for end of life care in acute hospitals’, workshops 1 & 2, Corporate Induction and other bespoke training as per department requirements.
Conclusion
In conclusion, if a similar event occurs in the future, due to the experience of the Covid19 pandemic, we will all be better prepared and the national and individual response is likely to be very different. The importance of providing dignified spaces for patients and families, particularly for those who are dying has been highlighted. The demand on healthcare facilities to provide equipment and other resources was immense, the cost to the nation to provide these resources and then to dispose of the waste generated is very significant and more sustainable products should be given consideration going forward.
The Pastoral Care Service has prepared the following submission which highlights the importance of Pastoral Care to patients, families, friends and staff at all times but especially during the Pandemic.
TUH Pastoral Care submission to COVID- 19 Evaluation
The healthcare chaplains of the pastoral care team provided spiritual, emotional and religious care to patients, their families and healthcare staff throughout the pandemic. This care was provided twenty four hours a day. In the midst of the pandemic the role of healthcare chaplains was in providing compassionate pastoral care to COVID-19 patients by being with them, holding their hands, talking and reading with them, with innovative practices making connections on the phone with their loved ones and rituals at their bedsides.
As key members of the multidisciplinary team we witnessed first- hand the experience of the patients in our care and their families. We also experienced the incredible work of our healthcare colleagues in caring for the sick, COVID-19 patients, the dying and dealing with the initial stages of death and bereavement. The pandemic put them under enormous strain and many described feeling stressed and exhausted.
Recommendations
- Pastoral Care Service
We strongly recommend that the COVID-19 evaluation recognises the need to offer holistic compassionate care for each patient in meeting their spiritual and religious needs and the place of rituals in end of life care. The provision of pastoral care services and specialist healthcare chaplains is a vital component of compassionate care and the pandemic has highlighted this as a justice issue. The value of highly trained, experienced and the skilled competences of healthcare chaplains in delivering end of life care for patients was a valuable resource of the hospital when faced with responding to the pandemic. The hospital chapel and contemplation room were sacred spaces in the hospital environment for staff to experience peace and quiet moments of refection and a place to refresh and renew themselves.
- Communications
In the early days of the pandemic there was much upheaval experienced in the hospital setting. The hospital applied policy and procedure in line with national guidance. Facilitation of visiting for patients at end of life was a significant challenge and despite trying to use a compassionate approach to facilitate visiting. At an earlier stage in the pandemic the reality was that in some situations family members were not present with their loved ones when they died. The impact of the restrictions will last for generations. Where visits were facilitated the experience for the family was deeply meaningful and every effort was made to meet their needs. The learning is that even when restrictions are in place we need to be better prepared and the restrictions must allow for clear communications and compassionate care that facilitates humans to have contact with the humans they need most in their difficult times.
Other areas of communication that healthcare chaplains experienced as reducing personal connection, PPE made spoken communication between healthcare professionals and patients difficult. This was a particular challenge for patients who have additional communication needs, including the deaf and those with impaired hearing, stroke patients and some autistic patients who depend on facial expressions to aid communication.
In Conclusion
The COVID-19 pandemic has highlighted the crucial importance of pastoral care (spiritual, religious and emotional) and the role of healthcare chaplains within the framework of holistic care, as a therapeutic healing tool for the body-mind-soul of the sick and dying, which helps reduce suffering. Pastoral care is a key element pivoting around compassion and cultural competence. The pandemic has unmasked the urgent need for centralised strategies to prepare healthcare systems and professionals in relation to spiritual support provision, both routinely, but also during health emergencies. Finally, research is required to explore the role of pastoral care and the innovative practices opened up by this coronavirus disease in terms of spiritual support provision ensuring spiritual support needs of all are better met.