Planning for an Influenza Pandemic
During a pandemic, a number of factors – such as a shortage of staff and hospital resources – may contribute to challenges in applying the College’s practice standards. Planning is key to determining how well a facility and its nursing staff will manage these difficulties.
Nurses across Ontario have submitted hypothetical situations that highlight the challenges of nursing during an influenza pandemic. Reviewing these scenarios can support you in developing strategies for applying the standards in the event of a pandemic.
This section is updated regularly. If you have a question or want to submit a scenario, contact your sector’s College Outreach Consultant.
Nursing During a Pandemic: Scenario #1
(Suggested by nurses at The Ottawa Hospital)
Over the past three weeks, an influenza pandemic has had an enormous impact on the medicine in-patient unit where Cindy, an RN, works. Recently, the unit became dedicated to clients with influenza. Today, one-third of the scheduled nurses are absent, and Cindy has been assigned four clients on top of her usual client load. She also has the timeconsuming task of putting on personal protective equipment with every client contact.
At the beginning of the shift, Cindy assesses her clients and takes their vital signs. For the remainder of the shift, though, she cannot check their vital signs as frequently as ordered, and she only has time to document abnormal findings. There isn’t time to assist the clients with daily hygiene tasks. Cindy also can’t administer all of the clients’ medications within the required time frame. She attempts to meet each client’s emotional needs but can only stop to speak with those who ask to talk to her. Cindy is aware of the College’s Preparing for an Influenza Pandemic fact sheet. She is concerned that she’s not meeting the College’s expectation of adhering to the practice standards and guidelines during a pandemic.
Prior to a pandemic, health care organizations need to create policies that establish procedures to follow during such a serious event. Advance planning can establish ways to avoid circumstances in which nurses find themselves faced with difficult decisions in a complex environment. It also provides employers with the opportunity to use foresight to set up the necessary resources, policies and organizational supports that nurses will need to provide safe, effective and ethical care.
During a pandemic, nurses need to use critical thinking to establish priorities that protect the client and add value to client outcomes. Cindy could collaborate with her team members to prioritize the clients’ care needs and eliminate any non-critical care activities; for example, they could reduce the frequency of taking the vital signs of certain clients. These decisions need to be communicated through documentation that reflects the assessment, intervention and client outcomes.
Cindy is concerned that she can’t meet all of her clients’ emotional needs. A nurse establishes and maintains the therapeutic nurse-client relationship through the use of professional nursing knowledge, skill, and caring attitudes and behaviours. During the initial introduction, it is important for the nurse to inform the client of the general composition of the health care team. At this initial meeting, Cindy could also indicate to the client that his or her essential care requirements will be met. In collaboration with the client, Cindy could outline what the client’s essential care needs are and inform the client of the expert resources available to meet his or her particular needs.
Sharing this information with the client helps place the therapeutic nurse-client
relationship in the context of the current environment. The nurse meets the Therapeutic Nurse-Client Relationship, Revised 2006 practice standard by actively including the client as a partner in the care. The nurse further meets the standard by discussing expectations with the client and informing the client of what will be done to meet critical needs given the available resources. To achieve identified client goals, it is essential to negotiate the role of the nurse and the client, including the client’s family members and significant others.
Cindy has responded to those clients who have asked to speak with her. Cindy could collaborate with the health care team regarding her concern about ensuring that all of her clients’ emotional needs are met. Through advocacy and collaboration, the team could develop a supportive infrastructure of volunteers, pastoral care workers, psychologists, psychiatrists and/or palliative care workers to provide a consultative/referral resource to assess/meet the clients’ psychosocial and emotional needs. During a pandemic, nurses need to be leaders in influencing organizational decisions to ensure the most efficient use of the health care team to meet client care requirements.
To prepare for a pandemic, it’s key to become aware of the expectations outlined in the College’s practice standards. The standards can help nurses understand their accountability and assist them in making informed decisions.
For example, the practice standards address issues around accuracy and timelines but do not establish specific medication administration times, documentation methods, frequency of assessments or hygiene requirements. The process of achieving these expectations needs to be established prior to a pandemic.
Identifying potential situations that may occur during a pandemic and working them through with the practice standards as a basis for decision-making allows both nurses and organizations to be proactive.
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Scenario #2
Jennifer, a community visiting nurse, is on a palliative care team. She is also a member of the pandemic planning team at her agency. While attending an in-service on the agency’s do-not-resuscitate policy, Jennifer reflects on a 78-year-old client, Mr. Shaw.
Mr. Shaw has a zest for life and a “we can beat this” attitude toward his illnesses. He has several advanced co-morbidities, including cardiac disease and diabetes, which have required daily nursing visits. Recently, Mr. Shaw was admitted to the local hospital. Jennifer anticipates that because his health has deteriorated, Mr. Shaw’s physician will advise him that CPR is not a viable option for his treatment plan.
Jennifer, thinking about the work of the pandemic planning team, wonders what would happen if Mr. Shaw was advised that CPR was not an option during a large-scale health emergency, such as an influenza pandemic. Would the client believe he wasn’t being offered CPR only because of the pandemic?
Jennifer decides to discuss this question with the pandemic planning team.
Exploring potential clinical scenarios promotes the best possible outcomes for clients in the event of a pandemic. Although health care staff and resources will be stretched in an emergency health situation, nurses must still provide safe, effective and ethical care.
Jennifer can demonstrate leadership by collaborating with the client and other members of the health care team to provide professional practice that respects the rights of the client, as described in the College’s Professional Standards, Revised 2002 practice standard. Jennifer may need to contact the client’s physician to find out what he or she communicated to the client and how the client reacted to that information.
She might want to ask the physician questions such as:
- What did you discuss regarding CPR?
- Do you feel CPR would be of no benefit because of the client’s current illness, the client’s co-morbidities or both?
- Was the decision against performing CPR made before or after the pandemic outbreak?
Then, Jennifer will need to document any outcomes or implications for the client resulting from the discussion.
She may also want to review the College’s Resuscitation, Revised 1999 practice standard. It states there is no legal obligation to provide a treatment that is of no benefit and is futile. In addition, there is an ethical obligation to do no harm.
Having accumulated this knowledge, Jennifer can make a meaningful contribution to the health care team’s plan to support the client. Following a number of discussions with the health care team, the client and family regarding the client’s disease process and the treatment options, the client and family conclude that CPR would most likely be harmful and futile.
Nurses can also obtain guidance in supporting the client and providing client-centered care by reviewing the Therapeutic Nurse-Client Relationship, Revised 2006 practice standard.
Key points for consideration that this standard raises are:
• discussing with the client his or her health and expectations, as well as available resources;
• recognizing that the client’s well-being is affected by the nurse’s ability to effectively establish and maintain a therapeutic relationship; and
• demonstrating sensitivity and respect for the client’s choices, which are based on the client’s individual values and beliefs, including cultural and/or religious beliefs (see the College’s Culturally Sensitive Care practice guideline).
Additional College practice standards and guidelines relevant to this scenario are available here.
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Scenario #3
In the paediatric unit of a community hospital, extended family members and close friends form part of the circle of care. In the event of an influenza pandemic, though, the hospital’s leadership team intends to restrict visitors. During a pandemic, only the parents or guardians of the paediatric client will be allowed to visit the child.
The unit’s nurses are worried that this policy will reduce their ability to provide family-centred care to the infants and small children in the unit.
Mary, an RPN, is concerned about how the restricted visitor policy will affect family dynamics. Aunts, uncles and grandparents frequently take shifts staying with the child in the hospital. Siblings visit on a daily basis, and parents have expressed how much they value being able to care for their children during a hospital admission.
Mary is also worried about whether her clients will receive enough attention, and whether the children’s developmental needs will be met with fewer visitors to interact with them. Also, as the pandemic progresses, there will be staff shortages as members of the health care team become affected by the influenza.
She has discussed these issues with the other nurses on the unit. Together, the unit nurses have alerted the hospital’s leadership team of their concerns.
Nurses, as leaders, need to advocate for organizational pandemic plans that reflect the care requirements and best interests of their clients.
It is important that Mary and the other nurses on the unit become familiar with all of the details of the organization’s pandemic plan. Then they can develop strategies to educate families and clients about the changes in hospital visiting policies. When discussing infection prevention and control, appropriate, timely communication strategies helps clients, their significant others and the community.
In collaboration with the health care team and clients’ families, Mary can develop a plan of care for her clients that will meet the professional standards during the pandemic. The professional standards are applied by demonstrating respect for, empathy with and interest in clients, and by developing collaborative partnerships with clients and families that respect the client and family’s needs, wishes, knowledge, experience, values and beliefs. By involving the family when an infant or child is admitted, a plan of care that will meet the needs of the client and the family can be mutually agreed on.
When direct visitation is not possible, innovative care planning – such as the use of technologies to link siblings and significant others to the client – could be considered. You may also want to ask other members of the health care team – such as unregulated care providers and pastoral care workers – if they are willing to perform other responsibilities, such as interactive play, to meet the young clients’ developmental needs.
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Scenario #4
Marion is an RN who works full-time in a 32-bed, secure Alzheimer’s unit in a long-term care facility. Three weeks ago, there was an influenza outbreak in the facility. The administrator and the director of resident care, in consultation with the medical director and the designated infection control professional, decided to “close the unit.” Closing the unit meant no one was admitted to the unit, there were no outside appointments or activities for residents permitted, and visitors, except for family members and non-essential staff, were limited. These actions were taken to minimize the spread of the influenza outbreak to other units in the facility and to the outside community.
The outbreak lasted for six days and did not spread to other units.
During the outbreak, the facility was consistently short-staffed due to staff illness. Marion was concerned that she and other nurses were working too many shifts to do their jobs properly. Marion felt that residents’ care needs were met with the assistance of residents’ family members and available staff. However, during a pandemic, family support would be limited and may be inadvisable.
Now that the outbreak is over, Marion has reflected on the challenges everyone faced. Marion is concerned that in the event of a pandemic, staff might not be able to meet residents’ care needs and the College’s expectations in the Infection Prevention and Control practice standard. She worries that if a resident needed to be transferred to an acute care facility during a pandemic some of the resident’s care requirement might not be met.
Marion has asked for a meeting with the director of resident care to discuss the facility’s influenza pandemic plan. Before the meeting, Marion plans to review the College’s Infection Prevention and Control, Ethics and Therapeutic Nurse-Client Relationship practice standards.
Marion demonstrated leadership by reflecting on the outbreak and asking to meet with the director of resident care. She is also prepared for her meeting by being aware of and using the resources that are available to her such as College practice standards.
Based on her reflections and follow-up discussion s with the director, Marion could work with the health care team to create potential clinical scenarios and plans to address them to promote the best possible outcomes for residents. Even though staff and resources would be stressed in a pandemic situation, she recognizes that nurses are still accountable for providing safe, effective and ethical care.
Marion should collaborate with colleagues within her practice setting (and potentially across practice settings) to create policies that establish procedures to follow during an event such as a pandemic. Planning in advance can help organizations establish processes for making difficult decisions in emergency situations. Such planning also gives employers the opportunity to anticipate the need for and set up the resources, policies and organizational supports that nurses need to provide safe, effective and ethical care to residents and their significant others.
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