The coronavirus pandemic is being compared to a battlefield, with health workers seen as the frontline soldiers in the war against the disease. There is certainly truth to that, insofar as doctors and nurses in many countries now face an unprecedented workload in saving lives, with a heightened risk of contagion from coronavirus and with the growing prospect of having to make difficult medical decisions in terms of allocating resources and continuing treatment.
While the coronavirus spreads, however, patients suffering from other diseases continue to require essential care. Cancer represents a particular challenge, as patients’ long-term prospects depend heavily on access to treatment that weakens their immune systems (chemotherapy, radiation) or requires hospitalization (surgery). In the balance, therefore, are risks of delayed care against those of infection.
“Many establishments are managing to keep cancer patients insulated but how to keep them – as well as the nurses – safe from contagion remains at the forefront of our concerns,” said Dr Stella Bialous, Professor at the USCF School of Nursing and Immediate Past President of the International Society of Nurses in Cancer Care (ISNCC). “We only hope that oncology nurses who are taking care of immune-compromised patients are not rotated out to coronavirus care and then back in again.”
The prospect of having to interrupt treatment is another major concern. One cause is the possible reduction in staff due to illness or indeed the reallocation of personnel for the coronavirus response.
Dr Shirley Ching, Associate Professor at the School of Nursing, the Hong Kong Polytechnic University and a 2016 UICC Fellow, explained how the SARS experience in 2003 allowed Hong Kong to rapidly adopt strategies at the outbreak of the coronavirus and continue cancer treatment without interruption. These include a complete suspension of visits, including to oncology wards.
“Oncology doctors and nurses communicate with family members, especially those of patients in critical condition, through telephone calls to update on the patients’ progress and provide psychological support,” Dr Ching said. “Some in-person consultations have been replaced by phone consultations to reduce patients’ travelling to hospitals. Nurses provide education and support that enables patients to manage their care and even continue with home chemotherapy through telephone calls. For those who must visit the hospital, nurses provide detailed explanations on wearing surgical masks and adopting proper hand hygiene practice, and screen them for fever, respiratory symptoms and travel history.”
In the UK, Mr. Andrew Dimech, Member of the ISNCC Board of Directors and Acting Chief Nurse at The Royal Marsden, which is dedicated to cancer diagnosis, treatment, research and education said that the response nationally has been remarkable, both within and between institutions, as departments and hospitals have come together to manage and allocate resources.
Mr Dimech said, “It is an enormous undertaking, which allows local hospitals to receive the support they need. The entire workforce is mobilised to ensure that adequate care is provided. Nurses with experience in critical care are given refresher courses, if necessary, to help on the coronavirus front – all nurses can play an essential role even in cancer care and other settings with adequate support.”
The Royal Marsden is continuing to deliver cancer care and treatment as well as providing local and national support in respect to coronavirus. “Decisions to delay treatment, if required for the safety of our patients, are made on a case-by-case basis by the patients’ multi-professional team. The Royal Marsden is engaged in continuing to provide treatment to patients for as long as possible,” said Mr. Dimech.
Another challenge to providing uninterrupted cancer treatment is a lack of material resources. Medication for cancer treatment is expensive, and many hospitals particularly in Low and Middle Income Countries (LMICs) may not be able to afford to continue cancer care, according to Professor Patsy Yates, President of ISNCC and Executive Dean, Faculty of Health, Queensland University of Technology in Australia. The continued availability of personal protective equipment (PPE) is another concern, as it not only protects nurses from infection but also when handling cancer medication. There is currently a global shortage of PPE.
“We also face the prospect of delays in screenings and other early detection diagnostics,” said Professor Yates. “As these actions influence the effectiveness of prevention and care, the coronavirus may, down the line, increase the disparities that already exist between developed nations and LMICs – regardless of whether treatments are interrupted or not.” This only adds to the inequality burden faced by LMICs, where exercising effective social distancing in poor, high-density urban areas is extremely challenging.
Supriya Mondal, Associate Professor at Murshidabad Medical College and Hospital, and Clinical Specialist nurse at the Aadarsh Nursing Institute in Raipur, Chhattisgarh, conveyed the disruption caused by the coronavirus and the resulting government lockdown on everyday life in India, particularly rural communities. A 2016 UICC Fellow, Ms Mondal has gained experience in facilitating the training of nursing staff and health care professionals in supportive care and counselling, and has conducted an epidemiological study of the coronavirus and its projected growth in India.
Ultimately, decisions to pursue or delay treatment have to be made with little guidance as to the optimal outcome, since so little is still known about the coronavirus. Lucy Gossage, an oncologist based in Cambridge, UK, writes in an opinion piece in The Guardian: “We will be counselling against treatments we would normally recommend. We will, no doubt, see some patients die sooner, not because of coronavirus but because we are not able to treat their cancers as we would normally.”
Another monumental decision that nurses and doctors may have to face is whether to treat a cancer patient who contracts coronavirus when essential medical equipment, such as ventilators, is in short supply. As a young nurse, Dr Bialous was part of a team that had to choose between providing a particular treatment to a young person with terminal cancer or an older person with cardiovascular disease – they could not treat both.
“No-one wants to be in that situation. You never forget. But we are reading about situations like this potentially arising in the US and elsewhere, and I wonder: if this is happening in wealthy countries, what about countries that don’t have the health resources to provide enough treatment?”
The primary concern, however, remains the shortage of nursing staff and the fact is, as Professor Yates and Dr Bialous emphasised, that the pandemic has only made worse a situation that already existed before. The WHO estimated in 2014 a need for more than nine million nurses by 2030 – according to a study from 2019, that shortfall is only projected to decrease by two million. Again, this disproportionately affects low-income countries and rural and remote areas.
“The best way to celebrate nurses is to have a real discussion on how to address this shortage,” said Professor Yates. “This will not be our last pandemic.”
There are discussions in the current crisis to graduate nurses early. “This may work in the northern hemisphere where graduation dates are very near, but in the southern hemisphere they graduate later in the year. Furthermore, we may not be able to assign them to specialized care such as oncology,” said Dr Bialous.
Nurses face extended work hours in already stressful conditions where there are staff shortages, and it cannot be denied that this will exact a psychological toll in the form of burnout and emotional distress, as well as generate anxiety about the nurses’ safety and that of their families if they are exposed to the coronavirus.
Andrew Dimech, Stella Bialous and Patsy Yates all emphasise that nurses will double down on to make up for staff shortages - because that is what they do. “Nurses are willing to make the necessary sacrifices if at the end of a shift they don’t see people ignoring shelter-in-place policies and disregarding the essential need for social distancing,” said Dr Bialous.
The public’s engagement is essential. It is the only way to mitigate the risks of overwhelming health systems even more. Dr Bialous would argue that it is not the nurses and doctors but individuals in every community who are the ones on the frontline of this battle against coronavirus. “It’s their response that will minimize transmission through social distancing to that health workers remain able to cope and deliver treatment as they were trained to do.”
Read the ISNCC COVID-19 Position Statement and the ISNCC blog on “The tailored meticulous nursing management dealing with COVID-19”.
Dr Stella Bialous will be co-organising on behalf of the ISNCC a session at the World Cancer Congress on “The way forward: leadership in disseminating evidence-based symptom management and improving the delivery of care”.
UICC numbers 26 ISNCC members and nurses among its more than 250 hospitals that are part of the UICC Membership. Through the SPARC programme, UICC has supported nurse training programmes as part of broader grant programmes, notably in Ghana and in Bulgaria. UICC Fellowships also provide nurses and other health practitioners with training and knowledge transfer.