Blog Post

COVID-19: Changing the Face of the Nurse-Patient Relationship

April 17, 2020

No matter the medical setting, COVID-19 is changing the way facilities and nurses interact with the residents/patients and their families, creating a shift in the traditional nurse-patient relationship.

Long-Term Care Facilities and Nursing Homes have utilized the same strategies within the facilities on an ongoing basis to detect and prevent the spread of other viruses. The Center for Disease Control and Prevention has developed a variety of guidelines and tools for Long-Term Care Facilities and Nursing Homes to use during the COVID-19 outbreak.

In addition to the standard infection control practices, the CDC has recommended some additional steps to take to decrease the spread of COVID-19 in the nursing home setting.  These recommendations include:

  • Restrict all visitation, except for certain compassionate care situations, such as end of life situations
  • Restrict all volunteers and non-essential healthcare personnel (HCP), including non-essential healthcare personnel (e.g. beauticians, entertainers)
  • Cancel all group activities and communal dining
  • Implement active screening of residents and HCP for fever and respiratory symptoms

The recommendation for residents with suspected or confirmed COVID-19 includes:

  • Isolating symptomatic residents as soon as possible. This means the facility is to set up separate, well-ventilated triage areas, place patients with suspected or confirmed COVID-19 in private rooms with the door closed, and a private bathroom as soon as possible.

Long-Term Care Facilities and Nursing Homes over the years have gone through a culture change to making socialization and increased family involvement a priority. Nurses and residents have become accustomed to daily socialization and physical contact with the residents and their loved ones.

With the CDC recommendations to prevent the spread of COVID-19 facilities are faced with how to maintain socialization while implementing the CDC recommendations. Some facilities and families have introduced and implemented alternative ways to enhance the resident’s safety while continuing to ensure their psychosocial needs are met. Some examples of this include having the residents Skype and FaceTime with their loved ones, virtual parties, loved ones visiting from outside the facility through windows. While these measures are necessary to prevent the spread of COVID-19 there are many psychosocial aspects of socialization that will be impacted.

Nurses are also faced with how to maintain the nurse-patient relationship, while ensuring the safety of all. One of the greatest impacted areas for this is in the hospital setting. Nurse-patient relationship is a critical component in the delivery of quality care. This nurse-patient relationship is not only beneficial for the family and patient but for the nurse as well. This relationship starts immediately upon the patient’s admission to the hospital. Nurses are taught to treat the patient holistically, which includes assessing their immediate needs, as well as those of their family, and provide the support needed. Patients and their family members are faced with harrowing decisions and it is the role of the nurse to provide support during this difficult time.

Support and education are usually performed at the bedside, or face-to-face. This allows the nurse to visualize non-verbal cues from both the patient and family. Often, more is communicated through non-verbal cues than speaking. Currently this face-to-face communication is not available due to the visiting restrictions imposed to uphold the social distancing guidelines.

Face-to-face communication at the bedside is now interfered by Personal Protective Equipment: a mask, gown and gloves. This prevents the patient from seeing the face of their medical care provider and can often create a barrier to effective communication.  Although PPE is necessary to provide safety, it takes away the intimacy of verbal communication or physical contact that many patients rely on for comfort.

Communication and the inclusion of family/significant others in the plan of care is also imperative to meet patient care goals. Sensitive situations such as end-of-life decisions will occur when the family is at bedside. Patient goals and treatments are often discussed throughout the patients stay with the multi-disciplinary providers (PT/OT, social worker, etc.) involved in their care. With current hospital visitation restrictions, this communication is now performed via the telephone to prevent physical contact, endorsing the social distancing guidelines.

Patients and medical providers now have limited contact with family/significant others.  This is a deviation from what nursing has always practiced.  This new norm impacts both the patient and families/significant others in several ways, including their psychological well-being.

For example, residents/patients and family members are likely to feel increasingly isolated from each other, as they no longer can rely upon the mutual support often experienced by regular visitation.  In addition, when end-of-life decisions are made via mechanisms other than face-to-face, an important element of closure is extremely difficult to experience.  Further, when families are no longer allowed to be bedside during a patient’s final moments, this can result in complications to an already sometimes difficult grieving process.

Still further, a significant percentage of residents in long-term care facilities may be dealing with the effects of a neurocognitive disorder (e.g., Dementia, Alzheimer’s Disease), and for these individuals, trust and consistency is critical for symptom management. Imagine the impact on these patients when formerly familiar faces are replaced with individuals wearing PPE. While it is difficult to know the full impact of such changes, it is reasonable to speculate that at least initially, the quality of the patient-nurse relationship will suffer significantly.

Speaking of the provider, it is important not to forget the impact that the changes described above will have on their ability to do their jobs in the way they had been trained. It is not unreasonable to assume many providers will experience increased levels of stress and feel dissatisfied with their job in the wake of not being able to provide for patients and perform duties in the manner in which they were taught and prefer. As such, the term “working anxious” has been used to describe individuals who provide care on a daily basis in environments that pose a potential threat to their health and well-being, as well as to the health and well-being of their significant others.

COVID-19 poses both direct and indirect challenges and threats to patients and residents, family members, and healthcare providers alike. Just as you have transitioned to working from home and the stressor and inconveniences that come along with that, care providers are in the office working anxious, which will catalyze future problems to combat.