Volume 40 Number 3

Introduction

Globally, nurses represent the largest single group of healthcare professionals in any country, which makes them central to the delivery of healthcare services. Nurses are the threads that form the organisational structure and fabric of the healthcare system. As members of the profession, enterostomal therapy (ET) / wound, ostomy, continence (WOC) nurses offer specialised care that is critical to the health of persons with wounds, ostomies and continence. As Ayello and Chabal note, coronavirus disease 2019 (COVID-19) has brought uncertainty to individuals and healthcare but has also shown how the world is interconnected¹. The COVID-19 pandemic has had serious implications for ET/WOC nurses, for example, risk of exposure, extreme workloads, moral dilemmas, and an evolving practice environment². Nonetheless, ET/WOC nurses’ knowledge and practice have positioned these nurses as integral partners who are involved in the delivery of care during these challenging times.

While ET/WOC nurses continue to make invaluable contributions to health, this pandemic has heightened their leadership role within the context of healthcare delivery. This is at a time when the year 2020 has been recognised as the Year of the Nurse with its theme of Nurses caring for the world³. This is a time to learn from, communicate with, and understand each other¹. One area for learning, communication and understanding that should not be overlooked for ET/WOC nurses during the pandemic is leadership. The aim of this opinion paper is to highlight five leadership themes for ET/WOC nurses that have evolved during the pandemic, namely interprofessional practice, emotional intelligence, ethical practice, advocacy, and self-care.

Five leadership themes

Interprofessional practice

Interprofessional practice rather than professional hierarchy in healthcare has had increased focus during COVID-19. This pandemic requires a coordinated and non-hierarchical, collaborative approach to the delivery of care. This calls for opportunities to not only learn from but also to learn with each other amid an environment where information about the pathology and virology of this organism is constantly changing. An example includes proning teams with members from nursing, anaesthesiology, physical therapy, occupational therapy, etc to safely position patients receiving mechanical ventilation and protect the skin.

COVID-19 has brought with it challenges as well as new opportunities to share ET/WOC practices and resources. For example, the Wound Ostomy Continence Nurses Society published a document for maintaining skin health when wearing protective masks for a prolonged time and treatment of personal protective equipment (PPE)-related skin damage^4–5. In this regard, ET/WOC nurse leaders are critical in shaping and creating opportunities for shared learning experiences among partners in health by sharing what they are doing⁶. For example, nurses, in general, have been part of the solution when thinking about how to deal with an insufficient number of respirators or PPE. ET/WOC nurses have been part of the solution to practise telehealth focusing on wound, ostomy, and continence care^6–7.

The environment in which teaching/learning takes place has also changed. Leaders in nursing education had to become technologically savvy in accessing and sharing information. This environment requires creative teaching strategies and team implementation to plan and deliver care about ostomies, wounds and continence, bearing in mind the pathology and psychosocial implications of these conditions during the pandemic. Wound prevention and care may also be focused on clinicians in order to prevent and treat wounds under PPE^4–5,8. Consequently, ET/WOC nurses must be actively engaged in interprofessional practice through evidence-informed contributions that are rooted in continuous learning and application of theory to practice.

Emotional intelligence

Second, leaders must have emotional intelligence and be sensitive to the needs of staff. COVID-19, with its epidemiologic uncertainties and occurrence of critical illness and death, has the potential to contribute untold stress among nurses, especially when dealing with the sequela of wounds. Since ET/WOC nurses spend time mostly in direct patient care, the stress can be intense and excessive. This stress may be associated with fear of acquiring, being diagnosed, and/or being an asymptomatic carrier with COVID-19, having to cope with the recurrence of death within the clinical environment, and the extended working hours in PPE. The situation may be exacerbated by limited resources that are available to staff, which heightens the stressors related to delivery of care. Therefore, mental health issues may be heightened in practice settings and result in potential burnout. The best approach to ensuring positive mental health among nurses in the midst of the pandemic remains unclear, but healthcare systems need to address stress on all nurses and offer psychosocial support graded by the severity of staff needs^9–10.

Even more concerning is the potential for stigma and discrimination of nurses from the public and family members who may feel a sense of vulnerability to the infection¹¹; actual violence against nurses was seen in Mexico¹². In an attempt to decrease the stress level of family members, some nurses have adopted ‘self-quarantine’ measures to protect their families. ET/WOC nurse leaders need to demonstrate sensitivity to the needs of nurses at the operational level as their stress may be associated with issues that are beyond the work environment. These may include fear of infecting family members as well as the physical distancing that may be required.

In reviewing the actions of leaders during the initial phases of the pandemic in China, researchers concluded that health personnel did not value the need for psychologists for themselves⁹. However, they valued the importance of being supported, such as with space for uninterrupted rest and available psychological support for patients who needed it. In this regard, ET/WOC leaders must be sensitive to the overt and covert behaviours of staff, especially those who may be experiencing higher levels of fear but are concerned about acknowledging it.

Ethical practice

Third, ethical standards of practice must be maintained for all care. Because of the severity of the disease experienced by some, the pathophysiological effects of COVID-19 have the potential for challenging ethical standards of care, especially in low resource countries and settings. This disease has had a significant economic impact on countries globally and has caused commensurate challenges for governments and policy makers to make the necessary emergency and critical care resources available. This situation is especially challenging when economic constraints are associated with general slowing of economic activity with its implications for further reduction in the gross domestic product (GDP) and the ability to procure necessary supplies and equipment. Since the major challenge associated with the disease is respiratory, the availability, accessibility and timeliness to access respiratory care resources are crucial. As part of the ethical standards of practice, ET/WOC nurses are affected by respiratory- and ventilator-associated equipment impacting patient recovery and wound oxygenation, as well as development of medical equipment-related pressure injury.

In resource-challenged settings, the ethics associated with healthcare delivery will become more evident. Needing to make decisions based on ethnics, socioeconomic or chronological age will arise. In recognising these ethical dilemmas, allocation of supplies should be guided by well-established, broadly applicable ethical principles, unless the characteristics of the outbreak justify different courses of action¹³. ET/WOC nurses have a critical role to play in ethical decisions since they are the leaders responsible for the procurement and distribution of resources for their patients. This is especially important as COVID-19 requires a different range of resources, and the economic challenges associated with procurement and allocation can be extremely challenging. ET/WOC nurses need to be included as decision makers on institutional ethics committees¹⁴. By extension, ET/WOC nurse leaders must act as surrogates and advocates for both the staff and the patients as part of the multi-disciplinary team, especially in decision-making to ensure equity in the distribution of resources while maintaining ethical principles and standards of practice. This advocacy may include helping decide nurse staffing ratios that are high and potentially dangerous in order to care for an unusually high number of patients. For example, in New York city, nurses in the COVID-19 intensive care units were taking care of at least five critically ill patients versus the normal 1–2 patients¹⁵. The ethics of disaster management are different from usual care, given resource limitations and the need to ration.

Advocacy

Fourth, ET/WOC nurse leaders need to advocate on behalf of self and their team in relation to burn out and resource mobilisation. COVID-19 has the potential to increase tension between the forces related to patients’ needs and adequate levels of resources to function effectively. Due to the exponential increase in the incidence of COVID-19, severe challenges have occurred between resource needs and the capacity of the institution to provide the necessary supplies that will ensure the highest level of care. The nature of COVID-19 demands ‘round the clock’ care of patients in high dependency and often in critical care settings. In care environments where the heightened risks to staff are enhanced by the unavailability of key material resources, including proper PPE, ET/WOC nurse leaders must not abdicate their responsibility as advocates. Nurses want some measure of psychological comfort in knowing that their nurse leaders are advocating on their behalf. The importance of this level of advocacy, especially when there is a perception of heightened potential risks, cannot be underestimated. Healthcare professionals desire visible leadership². Leaders should be innovative, understand sources of concerns, work to mitigate concerns, understand that decisions are not made alone, and express gratitude to staff².

This advocacy must be managed effectively by ET/WOC nurse leaders to foster realistic expectations, bearing in mind the economic and political environments in which they operate. Nevertheless, ET/WOC nurse leaders have become advocates on behalf of their patient as well as their colleagues. This level of advocacy can serve as a framework for motivating staff to develop a sense of shared responsibility for an effective turnaround of the impact of this pandemic.

Self-care

Fifth, self-care is critical in responding to one’s mental health. Leadership at the ET/WOC nurse level can be a lonely experience, especially when the leader thinks he/she is expected to have all the answers in an environment where there are more questions than answers. There is a need to leverage the impact of wound experts within the nursing and healthcare organisation through education and training. In actuality, healthcare professionals do not expect leaders to have all the answers but need to know leaders are capable of rapidly addressing issues². COVID-19 places ET/WOC nurse leaders in a formidable position; they act as mentors, motivators and surrogates for their staff and patients while managing their personal fears and inadequacies. A sense of humour is helpful, especially when the demands exceed reasonable expectations. Like their staff, they too have fears about exposure to infection and the attendant implications for infecting family members. This stress is exacerbated by having to ensure the availability of effective staffing in an environment where the potential for absenteeism is heightened. Staff may need to be rotated to ensure everyone has adequate time for rejuvenation and personal management.

ET/WOC nurse leaders must acknowledge their vulnerabilities and fears and seek positive strategies to alleviate distress. These strategies include developing ‘down-time’ schedules and working with colleagues to overcoming challenges. ET/WOC nurse leaders must find quiet spaces during the day where they may rebound with new energies to face their challenges. ET/WOC nurses must recognise that if they do not invest in their self-care, they may find their ability compromised to effectively serve the myriad needs of those for whom they have responsibilities.

Conclusion

COVID-19 has not only changed the landscape of clinical interventions but has also added a new dynamic to the understanding and importance of leadership in crisis settings. This is even more pronounced in an environment that is clinical in context. Under normal circumstances, nurses, including ET/WOC nurses, in low resource settings are not generally given the respect that they deserve as critical members of the healthcare team. However, the emergence of the COVID-19 pandemic has brought to the fore the centrality of teamwork for effective decision-making, especially in clinical settings where adequacy of resources is a challenge. This situation is exacerbated by not only the clinical demands that arise as a result of the pandemic but the humanitarian toll through death and the psychosocial issues associated with the overwhelming speed of the disease spread coupled with feelings of hopelessness¹⁶. Leadership needs to promote a reasonable vision for hope given the overwhelming sorrow. A nurse needs to feel ‘my best is good enough’ given the constraints in the environment.

Researchers argue that “What leaders need during a crisis is not a predefined response plan but behaviors and mindsets that will prevent them from overreacting to yesterday’s developments and help them look ahead”¹⁶. Nursing leaders have a central role to play in the development of an environment that is conducive to effective levels of performance. What is equally challenging is that nurses may not have had comparable clinical experience from a public health perspective with a viral pandemic such as COVID-19. Therefore, there is no template from which ET/WOC nurses and leaders could have developed a plan nor adjusted their actions in the interest of effective management and leadership. This situation requires learning on the move, while at the same time engaging in reflective practice in a dynamic situation that requires real time interventions. Some argued that leadership in this COVID-19 crisis requires speed rather than precision in an environment that is dynamic and challenging¹⁷. The learning curve may be steep since it will require interventions that are innovative and, at the same time, relevant in an environment where the economic survivability may be at stake and economic resources may be absent or sporadic. Can the lessons learned be organised, recorded and shared for the next generation to be better prepared?

Leaders in the COVID-19 crisis cannot continue to depend on a ‘top-down’ decision-making approach nor be limited to a few members of the team. It requires the mobilisation of resources and empowerment of others to be responsive to the changing dynamic within the organisation¹⁶. COVID-19 has also reinforced the importance of effective interprofessional collaboration as all members of the team must be engaged in finding solutions to address the crisis^16–17. While experience is required in normal and routine emergency situations, ethical leadership should be the hallmark of practice in an environment like COVID-19¹⁶.

The importance of reflective practice and self-care cannot be minimised as success in any initiative requires team effort. In this regard, leaders must be sensitive enough to realise that, in the end, it is team and not individual effort that will result in success. It is critical to celebrate of members of the team¹⁷.

COVID-19 presents leaders with unprecedented challenges. Its dynamic and uncertain future will continue to pose significant challenges, including financial, human resources and ethics^18–19. While nurses and ET/WOC nurses work on the frontlines, the nature and quality of leadership will influence their performance as well as the achievement of the organisation’s objectives. In summary, the five leadership themes of interprofessional practice, emotional intelligence, ethical practice, advocacy and self-care will continue to evolve and serve as a framework for supporting ET/WOC nurse leaders in being proactive for future crises, as well as position them to effectively represent the fraternity in the present as well.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Author(s)

Oscar Noel Ocho*
DrPH, MPhil, MPH, BScN, RN
Director/Senior Lecturer, University of the West Indies School of Nursing, St Augustine, Trinidad and Tobago
Email: oscar.ocho@sta.uwi.edu

Barbara Pieper
PhD, RN, CWOCN, BC-ACNS, FAAN
Professor Emerita, Wayne State University
College of Nursing, Detroit, MI, USA

Joyce Pulcini
PhD, PNP-BC, FAAN, FAANP
Professor, George Washington University School of Nursing,
Washington, DC, USA

Erica Wheeler
PhD, MA, BSc
PWR, Pan American Health Organization, Country Office,
St Clair, Port of Spain, Trinidad and Tobago

* Corresponding author

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