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Capstone Practicum COVID-19 Learning Experience

Delaware Technical Community College -Stanton Campus

NUR460-5W1: Nursing Capstone

Instructor: Dr. Kathy Sokola

Andrea DiMartino

April 16, 2021

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Capstone Practicum COVID-19 Learning Experience

To many, the year 2020 will be remembered as a year of fear, isolation, and the

polarizing politics that escalated the turmoil in an already divided nation by making the safety of

the population a footnote when compared to the financial losses of corporations throughout

America. To others, the isolation will be ongoing as they learn to go on without their loved ones

who were among the number who succumbed to the COVID-19 virus since it made landfall in

the United States on January 21st of 2020 (The American Journal of Managed Care, 2021).

Initially, the major concern for infection was individuals over the age of 65, and in particular,

those with comorbidities such as asthma, COPD, diabetes, renal failure, liver disease, or immune

deficiencies particularly related to cancer or organ transplantation. Some states, such as

Delaware were slow to respond to the developing pandemic by instituting limitations on

gatherings and mandating masks in public spaces. Other states, including Florida, moved at a

glacial pace in placing any kind of mandate beyond social-distancing and contributed to what

would later be coined “Super-Spreader Events” such as spring break vacations (Nietzel, 2020).

President Trump responded to this issue in a White House Press Briefing saying, “They’re

feeling invincible ... but they don’t realize that they can be carrying lots of bad things home to

grandmother and grandfather and even their parents” while discouraging spring break goers from

gathering. (Azad & Nigam, 2020).

The governing body of the state of Delaware initiated the response concerning the novel

coronavirus on March 12, 2020, by declaring a state of emergency which allowed the state to put

limitations on gatherings of 100 or more persons, empowered the National Guard to initiate their

response planning, and prohibited price gouging or undue price increases that would result from

supply issues surrounding the pandemic (State of Delaware, 2020). In contrast, the State of
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Florida announced a State of Emergency on March 9, 2020, to allow extension of government

powers and empowerment of the National Guard, permitted the temporary recognition of

licensure of medical personnel that came to aid with the COVID-19 response, and appointed

Florida Director of Emergency Management as the State Coordinating Officer during the state of

emergency (DeSantis, 2020). The primary difference between the two states is the recognition

Delaware displayed that this pandemic would require government mandates to limit the spread of

the disease, whereas Florida’s response focused more on ensuring that a medical response would

be possible to deal with the aftermath of large-scale infection rates, but efforts also focused on

the concerns of limiting the loss of income for businesses. Though the states had vastly different

approaches to their pandemic response plan and notable differences in their total populations,

they have both had similar outcomes as far as infection rates and the number of deaths.

Furthermore, both states have reported higher mortality rates among those ages 65 or older,

especially considering the higher likelihood of comorbidities and other underlying medical

conditions.

In Delaware, the flattening of the curve regarding transmission rates was the priority for

the Governor Carney’s mandates. On March 16th, just 4 days after the initial declaration of the

State of Emergency, Governor Carney issues his first mandates concerning closures and

restrictions to stop the spread of the novel coronavirus. Among these restrictions were the shift of

restaurants to carry-out or delivery only, the restriction of places of business where alcohol

accounted for more than forty percent of sales, and distancing requirements of 6 feet from other

patrons not from the same household (Delaware Division of Public Health, 2020). A stay-at-

home order was put into place on March 24th, just over a week after the initial State of

Emergency. In that interim period, a flurry of mandates were put into place to safeguard
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residents. Schools were closed and students learned to transition to distance learning while

school districts scrambled to provide appropriate curriculums to support the new learning

models. Included with the closure of schools was a distribution plan that expanded the school

lunch program so that families who needed nutrition assistance were still able to provide meals

to their children as they previously had through the Delaware Food Bank and other food

distribution centers. Places where public frequently gather, including fitness centers, health spas,

movie theaters, and bowling alleys were closed. As the weeks went on, gatherings were reduced

to 50 persons or less, with the exception of senior centers and assisted living facilities where the

maximum number of residents that could gather at one time was limited to 10 persons (Carney,

2020). By April 1st, 2020, The State of Delaware had recognized 368 positive cases of

Coronavirus and mourned the loss of 11 Delawareans (Delaware Health and Social Servies,

2020).

Conversely, Florida’s Governor Ron DeSantis mandated on March 17th, 2020 that

restaurants limit occupancy to 50% of their normal maximum, allow for parties of no more than

10 patrons, and maintain a distance of 6 feet between parties and suspended alcohol sales in

establishments that derived fifty percent or more of their revenue from alcohol sales, effectively

closing the bars and nightclubs. Additionally, Governor DeSantis did address concerns about

transmission by mandating that any person who has symptoms, contact with a positive

individual, or has traveled on a cruise ship or airplane must be screened before they could

continue to work in foodservice establishments and established recommendation for sanitary

practices to reduce the spread of the disease while keeping businesses open (DeSantis, 2020). On

March 18th, 2020, in an effort to preserve personal protective equipment used by healthcare

workers, Governor DeSantis ordered the postponement of non-emergent and elective surgeries in
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addition to orthodontic, dental, and ophthalmic procedures. Finally on March 24th, following

President Trump’s participation with the CDC in creation of the “15 Days to Slow the Spread”

campaign, Governor DeSantis issued a restriction on gatherings to 10 or fewer persons and urged

that individuals able to work remotely would begin doing so. Finally, with this executive order,

the Governor also issued a public health advisory urging persons over 65 years of age to stay

home to limit their exposure risk, particularly those with underlying medical conditions

(DeSantis, 2020). This was a major concern as over 19 percent of permanent residents of Florida

are over the age of 65, the highest percentage in the nation (Kent, 2020). The Governor did not

address the issues of defining essential businesses or activities until April 1st, when a stay-at-

home order was finally put in place. By that point, there were nearly 7,000 confirmed cases of

COVID-19 and 86 deaths (Florida Department of Health, 2021).

Mandates surrounding face coverings were one of the more polarizing issues of the

pandemic. Political rivals used their opinion on mask mandates as a platform due to 2020 being

an election year. Demonstrations and refusal to adhere to masking mandates were common with

some political groups insisting that mask mandates were a violation of their constitutional rights.

These politically motivated arguments acted as a barrier to public adoption of mask use.

Florida’s Surgeon General, Scott Rivkees, mandated mask use in public as of June 20th of 2020,

with exceptions only for those with medical conditions that prevented compliance, or if the mask

posed a suffocation risk such as for children under the age of two. It was endorsed by Governor

DeSantis on the June 22nd as a revision to the State of Emergency (DeSantis, 2020). Delaware’s

Governor John Carney initiated a mask mandate on April 28th of 2020. It had the same

exclusions as Florida but indicated that for persons unable to wear masks that a business could

find alternative accommodations including appointments and delivery services to ensure that
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other patrons were protected but persons with disabilities could be accommodated under the

Americans with Disabilities Act (Carney, 2020). Other accommodations mandated by the

Americans with Disabilities Act were more difficult to oblige such as handicapped parking

because entrance and exit locations were adjusted in most establishments to provide proper

social distancing for customers.

By April 10th of 2021, Florida had a total of 9,679 positive cases and 158 deaths per

100,000 residents (about the seating capacity of the Los Angeles Memorial Coliseum) compared

to Delaware which had 10,085 positive cases and 162 deaths per 100,000 residents (Centers for

Disease Control and Prevention, 2021). The primary difference between the states is in the

demographics of their populations. For Delaware, residents over the age of 65 represent 19.4

percent of the population (US Census Bureau, 2019). As of April 10th of 2021, the state has seen

13,586 positive geriatric cases, which is approximately 14 percent of all cases, and 1,312 deaths

of individuals over 65 representing 83 percent of all COVID-19 related deaths in the state. In

Florida, approximately 20.9 percent of the population is aged 65 and over (US Census Bureau,

2019). By April 10th of 2021, the state has seen 303,402 positive geriatric cases, 14.5 percent of

all cases, and 28,234 deaths of individuals over 65 representing 83 percent of all COVID-19

related deaths in the state (Florida Department of Health, 2021). This data shows that regardless

of state, the infection rates and death rates are similar with mortality for persons over age 65

being the highest among all other age groups. Statistics and totals of cases and mortality rates are

ongoing while the nation continues to gain control over the spread of the COVID-19 virus.
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These trends and statistics are fairly consistent across the nation with a disproportionate

number of individuals over the age of succumbing to the COVID-19 virus due to the higher

likelihood of comorbidities including COPD, Congestive Heart Failure, and other disease

processes which impede gas exchange or tissue perfusion. Though the number of elderly

Americans who contract the coronavirus has been low due to protections in place for this

vulnerable population, there are specific conditions and situations which increase their likelihood

of contracting COVID-19, particularly of note the situation of living in a care facility either in an

assisted living situation or a skilled care facility due to their communal nature and staffing needs

(Centers for Disease Control and Prevention, 2020). Due to these issues, the elderly represent

one of the smallest demographic populations of the nation but has suffered a disproportionately

high number of deaths across the United States due to coronavirus infections.
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As of the writing of this paper, the restrictions that remain in place for both states are

different and may explain why spikes in infection rates are once again on the rise for both states.

In Delaware, Governor John Carney has modified the restrictions on gatherings to move

residents into phase two of the reopening plan. Indoor gatherings are still limited; however, the

limitation is now 25 persons or 50 percent of the venue’s capacity, whichever is smaller. The

exception to this is restaurants with indoor dining which have the dining capacity at 50 percent

but only individuals in the same household may sit together. Outdoor gatherings are limited to

150 individuals or 50 percent of the capacity of the venue if that location has fire occupancy

restrictions, but social distancing and masks are still required. Private get-togethers are limited to

10 people. Delawareans must still maintain social distancing and wear masks when in public

(State of Delaware, 2021).

Conversely, in Florida, there are no longer any capacity limitations unless imposed by

county or city officials who must also justify the restriction based on public health concerns.
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Masks are required in many locations, but not everywhere, and social distancing is encouraged

but no longer mandated. The beaches are fully open with no capacity limitations. Restaurants,

gyms, and retail centers are permitted to be open at full capacity but are requested to encourage

appropriate distancing and sanitation procedures. Although the state began lifting many

restrictions as early as September of 2020, officials are still encouraging senior citizens to stay at

home and limit their exposure to the COVID-19 virus, recognizing the higher risk of infection

and mortality related to the novel coronavirus, especially due to the increased prevalence of other

underlying medical conditions (Florida Tourism Industry, 2021). Although theme parks,

stadiums, and beaches are open there is still a “Conditional Sailing Order” for cruise ships which

requires certification and onboard testing (Centers for Disease Control and Prevention, 2021),

however that restriction is put in place at a federal level and not dependent on state intervention.

As vaccines became available at the end of 2020, states have had leeway to direct

distribution to fit with their individual state’s needs. For Delaware, the initial focus was on

healthcare workers, first responders, and senior citizens in long-term care facilities. However,

when an unexpected influx of vaccine availability was delivered, the rollout was scaled to

include individuals 65 and older who had underlying medical conditions. Later, as the

vaccination effort continued, all persons over the age of 65 became eligible (Delaware Division

of Public Health, 2021). This was not without challenges and roadblocks. For seniors in

Delaware to register, they had to go online to complete the registration process, often through

websites for the local pharmacies, unless their provider offered the vaccine which became a

possibility later in the vaccine rollout process but was not initially an option. This posed a

challenge for seniors who lacked access to the internet or who were not computer literate. As the

rollout continues, seniors are still the highest priority in vaccination; however, little has been
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done to address literacy and access issues on a governmental level. Much of this barrier has been

addressed by nurses, healthcare providers, and family members who have stepped in to advocate

for this population.

Initially, Florida’s response was similar to that of Delaware. The priority vaccinations

were given to frontline health workers and individuals over the age of 65; however, those

individuals had to prove residency in the State of Florida. Residency is determined as living for

greater than 30 consecutive days within the state at a consistent address (Florida Department of

Health, 2021). Because of this, Snowbirds, seniors who live in Florida for part of the year to

avoid colder temperatures, who normally maintain residences in other states could still be

considered a Florida resident as long as they stayed at their residence in Florida during the initial

rollout. Unlike Delaware, Florida’s Governor Ron DeSantis utilized not just the pharmacies and

hospital systems to distribute the vaccine to the population, but utilized his executive power

under the State of Emergency to mobilize FEMA (Federal Emergency Management Agency) to

provide mass vaccination sites focused in areas of dense population including Tampa, Orlando,

Miami, and Jacksonville which could each vaccinate up to 2000 people daily, and two additional

mobile vaccination sites that could treat an additional 500 Floridians daily (Florida Department

of Health, 2021).

The vaccination initiatives have not been without their own challenges. Availability of

vaccine doses has been challenging at times requiring some facilities to postpone second doses of

both the Pfizer and Moderna versions of the vaccine. Storage requirements of the Pfizer vaccine

posed a barrier due to the temperature requirements being overwhelmingly difficult to create at

small vaccine clinics and mobile vaccine units which further limited use of that vaccine type to

larger-scale vaccine operations organized by the major hospital systems or FEMA coordinators
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(Centers for Disease Control and Prevention, 2021). Compliance in some groups for a second

dose was a concern, particularly homeless populations, but that was resolved when Johnson &

Johnson’s single dose vaccine was introduced. Unfortunately, that vaccine’s efficacy was

slightly lower than that of Pfizer and Moderna, and manufacturing issues paired with unforeseen

side effects have put administration of the Johnson & Johnson vaccine on hold as of the writing

of this document (Marks, 2021).

To evaluate the impacts of the pandemic on Delaware’s hospital systems and geriatric

populations, a questionnaire was developed to analyze the different challenges across the state.

For a broad perspective, nurse leaders in three separate healthcare facilities were asked to

complete the questionnaire, two from major hospital systems and one from a rehabilitation

facility. There were some noted differences but also several concerns brought to light about ways

the elderly are being affected by this pandemic beyond infection and mortality rates. Initially all

three facilities were closed to visitors to protect patients and staff from unnecessary exposure

risks. Over time some accommodations were made based on the facility. One facility allowed a

family representative to have limited visitation but required that the representative be the same

person throughout the patient’s stay. Other facilities, such as Christiana Hospital restricted

visitation to only hospice patients initially, but later allowed one visitor to confused patients to

improve patient outcomes for those, particularly with dementia, who depended on the

consistency of their care provider, however the duration of the visit was still limited, and

permission only granted at the discretion of the nursing staff. As time has gone on the limitations

on visitors for all facilities have been relaxed, but open visitation is not currently permitted at

any facility.
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Though nationwide shortages of protective personal equipment (PPE) were a barrier to

proper care for many healthcare workers, the three facilities in Delaware noted that although

some of the suppliers changed through the course of the pandemic, there was no time when

choices had to be made for going without needed equipment including masks, gloves, and

isolation gowns. All three did have to reuse masks initially and report not changing surgical

masks as frequently as they would have pre-pandemic, with masks being reused for up to three

consecutive days while supply distribution was initially slowed. Holding other healthcare

workers accountable for maintaining handwashing or doffing procedures was also a concern,

especially in regard to preventing the spread of the virus within the facilities. As efforts ramped

up to roll out vaccines across the state, there were some unexpected shortages including 22-

gauge needles and 1 milliliter syringes, both of which are favored for vaccine administration.

The largest shortage noted for all facilities was staffing. This issue has led to increased patient

acuity, and increased patient ratios for nurses. Additionally, there have been more barriers to

time off due to these staffing issues including understaffing resulting from both insufficient staff

employed for each unit combined with nurses being shifted to other units to cover for personnel

that are ill which have contributed to fatigue and burn-out.

Staffing shortages and lack of bed availability at other facilities is contributing to the

issues surrounding patient care at inpatient facilities as well. Without beds available for safe

discharge, units are unable to make room for new patients and length of stay has increased,

particularly among the elderly who are more likely to require an intermediary level of care prior

to discharge to home or their normal care facility. In addition to being medically cleared, patients

must be rescreened for coronavirus prior to discharge to a skilled nursing facility even if they

have no outward symptoms of COVID-19. If they test positive for coronavirus, a bed must be
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found for them either within the hospital or at a facility with units specifically dedicated to caring

for individuals who have coronavirus. For patients on dialysis, the availability of

accommodations outside of in-hospital stays have been a huge barrier to discharge due to

isolation and transportation requirements for these patients on multiple days of the week and the

already elevated risk of these patients for complications. Other issues arose as facilities and

providers were hesitant to take patients who had recovered from coronavirus making it more

difficult to coordinate home care, facilitate meetings with patient liaisons, or find appropriate

placement in skilled nursing facilities. These delays in discharge increase a patient’s risk of harm

and can further extend the rehabilitation needed to return them to their earlier baseline of

mobility and independence.

Issues related to the pandemic but not directly linked to COVID-19 have been noted to

impact the elderly population at a disproportionately high rate. These include access to health

care providers and timely interventions of care. Nurses have noted a trend among the elderly

population of delaying seeking care for exacerbations of existing conditions that result in more

severe complications due to fear of exposure to the coronavirus or a lack of in-person care

available. Noted examples include disease processes that have symptoms similar to COVID-19

such as exacerbation of congestive heart failure and pneumonia which initially present as

shortness of breath, or infections which result in elevated temperature. Another barrier noted, not

just for patients to see healthcare providers but also for access to vaccines, is the proportion of

the elderly population that struggle with computer literacy. With much of the healthcare response

converting to telehealth practices and state vaccination registration being developed as an online

platform, many individuals over the age of 65 experience challenges navigating the services that

are available and rely on family, friends, and their healthcare team to not only educate them, but
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to help them in seeking out available services. Finally, a disturbing and concerning trend among

this population is the severity of care-related injury that they are presenting with in hospitals.

This includes stage 3 or higher pressure injuries that result from insufficient repositioning of

patients or their medical devices, increased severity of wounds related to infrequent dressing

changes, and as one nurse noted the general cleanliness of patients has decreased which could be

directly attributed to staffing shortages at care facilities where activities of daily living (ADLs)

are not being observed as frequently or thoroughly as is needed for these patients which

increases the prevalence of skin breakdown and patient harm. One respondent, a nurse certified

in wound and ostomy care (WOC) indicated that the increased incidence of skin impairment,

particularly pressure ulcers requiring wound vacs, reduced the patient’s tolerance for necessary

physical therapies and further extended their inpatient stay.

A major and ongoing concern for the geriatric population as a whole is the isolation

related to COVID-19. The patients in facilities have the benefit of interactions with staff, though

even that can be lacking. They have often been isolated for long periods, even in various therapy

sessions, from any persons outside of their healthcare team. Technology was used to help bridge

the gap, but resources and time constraints continued to be an issue, especially with tablets and

devices which allowed communication from within the hospitals. In the community, elderly

individuals are staying home, fearful to leave because they know that their chances if they do

contract COVID-19 are not good. Some are adapting with technology such as facetime on tablet

devices or zoom calls, but those interactions lack the meaningful connection that humans need.

Nursing care is more than treating a disease process, which has been the primary concern during

this pandemic. As time goes on, nurses need to return to a holistic model and realize the long-

term effects, especially for our seniors, when they have been isolated and fearful for so long.
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References
The American Journal of Managed Care. (2021, January 21). A timeline of COVID-19

developments in 2020. https://www.ajmc.com/view/a-timeline-of-covid19-developments-

in-2020.

Azad, A., & Nigam, M. (2020, March 20). Yes, young adults are sick and spreading coronavirus

-- but they can help stop it. CNN. https://www.cnn.com/2020/03/20/health/covid-19-

young-adults-sick-spreading/index.html.

Carney, J. (2020, December). Office of the Governor Archives. State of Delaware News.

https://news.delaware.gov/category/governor/page/1/.

Centers for Disease Control and Prevention. (2021, April). CDC COVID Data Tracker. Centers

for Disease Control and Prevention. https://covid.cdc.gov/covid-data-

tracker/#cases_totalcases.

Centers for Disease Control and Prevention. (2021, April 2). CDC COVID-19 Orders for Cruise

Ships. Centers for Disease Control and Prevention.

https://www.cdc.gov/quarantine/cruise/covid19-cruiseships.html.

Centers for Disease Control and Prevention. (n.d.). Healthcare Workers: Information on

COVID-19. Centers for Disease Control and Prevention.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html.

Centers for Disease Control and Prevention. (2021, April 15). Myths and Facts about COVID-19

Vaccines. Centers for Disease Control and Prevention.

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html.
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Centers for Disease Control and Prevention. (2020, September 11). People who live in a nursing

home or long-term care facility. COVID-19. https://www.cdc.gov/coronavirus/2019-

ncov/need-extra-precautions/people-in-nursing-homes.html.

Delaware Division of Public Health. (2020, December 22). Coronavirus (COVID-19) Data

Dashboard. Delaware's Coronavirus Official Website. https://coronavirus.delaware.gov/.

Delaware Division of Public Health. (2021, April 6). COVID-19 Vaccine. Delaware's

Coronavirus Official Website. https://coronavirus.delaware.gov/vaccine/.

Delaware Health and Social Servies. (2020, April 3). COVID-19 Update April 1, 2020: Public

Health Announces 1 Additional Death, 49 Additional Positive Cases. State of Delaware

News. https://news.delaware.gov/2020/04/01/covid-19-update-april-1-2020-public-health-

announces-1-additional-death-49-additional-positive-cases/.

Delaware Health and Social Services. (2021, April). State of Delaware. My Healthy Community.

https://myhealthycommunity.dhss.delaware.gov/locations/state/deaths#deaths-

demographics.

DeSantis, R. (2020). 2020 Executive Orders. Florida Governor Ron DeSantis.

https://www.flgov.com/2020-executive-orders/.

Florida Division of Emergency Management. (n.d.). COVID-19 (Coronavirus).

FloridaDisaster.org. https://www.floridadisaster.org/covid19/.

Florida Department of Health. (2021, April 10). Florida COVID-19 Response. Florida

Department of Health COVID-19 Outbreak. https://floridahealthcovid19.gov/.

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Florida Department of Health. (2021, April 5). Latest Vaccine Updates. Florida Department of

Health COVID-19 Outbreak. https://floridahealthcovid19.gov/latest-vaccine-updates/.

Florida Tourism Industry. (2021, April). COVID Travel Safety Information. Visit Florida.

https://www.visitflorida.com/en-us/current-travel-safety-information/covid-travel-safety-

information.html.

Kent, L. (2020, July 27). Where do the OLDEST Americans live?

https://www.pewresearch.org/fact-tank/2015/07/09/where-do-the-oldest-americans-live/.

Marks, P. (2021, April 13). Joint CDC and FDA Statement on Johnson & Johnson COVID-19

Vaccine. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-

announcements/joint-cdc-and-fda-statement-johnson-johnson-covid-19-vaccine.

Nietzel, M. T. (2020, June 19). New Study: College Spring Break Helped Spread The

Coronavirus. Forbes. https://www.forbes.com/sites/michaeltnietzel/2020/06/19/new-study-

college-spring-break-helped-spread-the-coronavirus/?sh=abee7654e52b.

State of Delaware. (2021, April 13). Coronavirus News from State Agencies. Delaware's

Coronavirus Official Website. https://coronavirus.delaware.gov/newsroom/.

State of Delaware. (2020, March 16). Governor Carney Declares State of Emergency to Prepare

for Spread of Coronavirus (COVID-19). State of Delaware News.

https://news.delaware.gov/2020/03/12/governor-carney-declares-state-of-emergency-to-

prepare-for-spread-of-coronavirus-covid-19/.

US Census Bureau, U. S. C. (2019). Census.gov. https://www.census.gov/.

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Appendix A: Practicum Hours Verification Log

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Appendix B: Reflections on Log and Key Points

COVID-19 Mandate Timelines: As research was done on the different mandates, it was at

times overwhelming to sort through all of the available information. Changes in the beginning

happened from week to week as information about the pandemic was better understood. Some

states, such as Delaware have made it easier to find the individual mandates, but in order to find

specific information about certain orders and requirements one had to search each and every

mandate to find the exact details.

In contrast Florida’s chronological mandates were harder to locate as their state’s website

was updated with the latest information and organized by topic. Certain information about

specific demographics was easier to find this way, but it was a challenge to find the initial

responses because of the vast number of changes that have been made to the initial State of

Emergency declaration. To further this, the Governor delegated some parts of the response to

different officials, including the Surgeon General, which is a great choice in ensuring the science

is followed, but a challenge when consolidating information.

Beyond the state mandates, seeing a lack of official Federal intervention was frustrating. I

had hoped to include more information on a federal level as far as requirements or responses to

shortages, but the federal assistance was so minimal that most of the reporting on it was from

major news organizations and the bias in the stories was frustratingly obvious. Without reliable

sources, much of the federal information came from the CDC. Utilization of the World Health

Organization as a resource was avoided because although they are a reputable source, their

recommendations and information strayed at times from America’s responses. This can be
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attributed to the break from the WHO that was ordered by then President Trump at the height of

the pandemic.

Overview of what was read and watched: The American Nurses Association was an important

resource, not just for issues surrounding specific populations or issues for healthcare workers,

but also in highlighting skills that were needed for review for patient safety. The refresher videos

on tracheotomy care and trach management were a boon, not just for this project, but in

professional practice as well. As patient numbers soared the medical surgical floors saw patients

they may not normally see, including trach patients. Additionally, highlighting the proper

techniques for donning and doffing of PPE opened dialogue on hospital units about how to

address proper infection control practices and holding one another accountable. Other issues,

such as addressing racial disparities and talking to minority populations about the vaccine were

timely and important issues, especially since they are topics that are often difficult to discuss

from the perspective of a Caucasian nurse.

With the novel coronavirus being such a newcomer to the research arena, seeking out

peer reviewed studies was extremely difficult, and those that were available didn’t relate directly

to the population or topics related to this project. The vast amount of information out there is

interesting and at times contradictory. An example of this was the early study that indicated

acetaminophen exacerbated the disease processes of COVID-19 and worsened symptoms. As

more information becomes available because the long-term effects of COVID-19 become

clearer, more peer-reviewed research about the impact on the mental health of our nation, and in

particular our elderly population and other issues surrounding the country’s recovery from

COVID-19 will be vital in fully understanding the far-reaching effects of this pandemic on

nursing, healthcare, and America’s population at large.

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Nurse Leaders in the Pandemic: The questionnaire was difficult to develop initially. Wording

questions that would get answers that pertained to the specific topic, but not biased in any way

that would alter the responses of the participants was a challenge. Contacts were sought out to

get a broad overview of the Delaware response outside of Christiana Hospital. I was able to

reach out to friends of friends to find nurse leaders who were in a position to give a perspective

in differing specialties and varied patient situations.

Analyzing the survey responses was the most telling part of the research as it pertained to

the geriatric population. Though mandates and raw numbers gave an overview about how the

elderly were impacted by this pandemic, understanding their trials, frustrations, and isolation

through the eyes of different nurses was revealing. I could sense the frustration they all shared in

the staffing issues and how that disproportionately impacted older adults. As nurses, we are

taught to care for the whole person, but this pandemic has turned healthcare into more of an

assembly line of symptom management with minimal patient contact and a traumatic impact on

healthcare workers.
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Appendix C: Questionnaire for Nurse Leaders

Hello. I'm Andrea DiMartino, a Registered Nurse pursuing my BSN through DTCC. Due to the

current challenges presented by the COVID-19 pandemic, we have had to pivot and find new

ways to complete certain aspects of the program including the practicum portion to adjust to

new facility requirements. As a portion of my new capstone project, I have researched the

course of the pandemic and how it has impacted my chosen population, adults over the age of

65. Could you help me by answering the following questions? Each of you work with

populations at different facilities which helps me to get a broad view of how my population is

impacted at different levels of care and at different hospital systems within the state. Please

complete the following questions and send me the response as soon as you are able.

1. Please describe how COVID-19 has impacted patient care in your hospital or care unit.

As an example, throughout the pandemic have you had adequate staffing, issues in

acquiring any supplies or protective equipment? Have areas been opened to deal

specifically with patients infected with COVID and did those new units put additional

strain on supplies or staffing ratios?

2. How have patients been impacted by mandates and limitations in your hospital system?

Are visitors permitted? Have they found ways to encourage socialization without

endangering patients? What measures have been put in place to ensure patient safety

in regard to cohorting rooms and preventing cross-contamination from staff and

equipment?
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3. Can you think of any barriers or limitations to patient care that have resulted from the

COVID-19 pandemic?

4. What changes have nurses in your hospital system seen as far as their responsibilities

because of the pandemic? Have there been system changes to adapt to any increased

workload?

5. Have there been new barriers to discharge for patients? If your patients typically are

discharged to a lower level of care, either by transfer or discharge to a rehabilitation

facility, what new barriers or challenges are you encountering that impact those

transitions? Are there changes to transportation requirements, testing needs, or lack of

open beds?

6. Have you seen any challenges for the 65+ population that put them at increased risk

when compared to younger adults? Do you see any increased patient harm or specific

issues directly related to care that could be a result of the pandemic?

7. Have you found that the patients in this population are more inclined to follow the state

mandates, such as mask adherence, and what challenges have you seen for this with

your patients?

Response 1: Sarah Howard BSN, RN

IP Rehab Clinical Educator
Bayhealth Inpatient Rehabilitation
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1. In the initial stages of COVID-19, once discharged from ICU, infected persons were sent

to a specified unit, which was originally an acuity adaptable unit. This also became full,

so overflow was sent to one section of our inpatient rehabilitation floor. Staffing was

arduous, especially as more nurses had to test and/or quarantine. Staffing ratios definitely

suffered. Areas in acuity adaptable that were typically 3 or 4:1, were now 5:1. Rehab

which is typically 5:1 now became overflow with nursing taking 6 or 7:1. Many of our

travel nurses vacated their assignments with our hospital in favor of big city ICUs that

were paying extreme wages for covid units in high infection areas. Supplies were handled

well by our central supply department, and no extreme shortage was noted.

2. Visitation has been restricted from the start. Only recently has visitation opened up to one

visitor a day (must be same visitor throughout stay) between 2pm and 6pm. Nursing and

social work have worked to bridge the gap of socialization by assisting patients with face-

timing their families or making voice calls. Non-essential activities were stopped,

supervised dining was cancelled and now staff must accommodate therapeutic dining in

patient rooms on an individual basis, group therapies are no longer in practice. All rooms

are private at my facility, so we haven’t had much of an issue with cohorting, although

when a patient goes to dialysis or physical therapy, measures have been taken to ensure

appropriate spacing, limiting the number of patients in one area at a time, the placement

of physical barriers between areas of care and the use of PPE and frequent sanitization to

prevent cross contamination in areas that cannot be avoided. All equipment is sanitized

with approved solutions between each patient, which does slow things down a little due

to recommended dry times of each solution.

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3. Many of our elderly patients are avoiding physicians’ offices and emergency rooms as a

result of covid-19. So when they have a CHF exacerbation for example, they are ignoring

symptoms that could be managed at a primary care level, because they didn’t want to be

exposed in the office, or didn’t feel that they were “sick enough” in comparison to those

who have covid. Because these symptoms are being ignored, by the time they are finally

addressed, they are to the point where hospital admissions are unavoidable. So now our

sick patients are sicker than ever. This complicates the burden on the nurse and all

hospital resources.

4. Nurses and CNAs were, and still are, working with higher ratios when compared to pre-

covid workflows. There has been a big push for the onboarding of traveling nurses and

international nurse contracts in order to help alleviate the staffing deficiencies.

5. Patients who are returning home have families involved with a “family training” to help

ease the transition back home and decrease caregiver stress. With the new visitation

policies, we are only able to train one caregiver, thus relying on that person to train

everyone else who may be assisting the patient post-discharge. If a patient requires

outpatient dialysis post discharge, difficulties lie in placement. Some outpatient dialysis

centers have been designated as covid-only. So if the patient was diagnosed with covid at

any point, they must test negative twice before being allowed back at their home center.

If their home center was made into a covid positive center, we must find them a new

temporary center before being discharged. For those who are going to subacute centers,

lack of open beds are a huge problem. Or if you are able to get a bed approved, then

someone in that center tests positive, the entire center quarantines, thus cancelling your

bed that you obtained.

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6. Being in acute rehabilitation, our patients are coming to us after lengthy ICU and acuity

adaptable stays and we have definitely seen a huge increase of pressure injuries on

admission to the unit. Additionally, these longer stays on medical floors are evident in the

extreme debility that our older population exhibits. The younger population declines in

strength at a slower rate than our 65+ community. In the higher acuity floors, the patients

are many times not performing any ADLs outside of the bed. By the time they get to

acute rehab, they lack the core strength to even sit unsupported for 15 seconds, let along

walk to a bathroom, which is harder to recover in our older population.

7. I find this is really varies from patient to patient and is dependent on the patient and level

of education we are able to provide to the patients. A lot of post-covid or family of post-

covid are mask resistant because they are in the mindset that they’ve had it already, so

they can’t get it again. Or they were already exposed by their family member, so they are

immune. A lot of education is needed to explain the disease process and reinfection rates.

I do find that overall, the older population are more adherent when given the information

and resources to comply with the mandates, such as setting them up with the state

programs that allow for food and medication delivery.

Response 2: Erica Mcdevitt BSN, RN

Wound Care Nurse, Infection Control Nurse

Encompass Health

1. As the Infection Control Nurse at our facility, there were many changes constantly

occurring. We had to come up with a protocol for something we had very little

information on at the time, but knew we had to keep the patients and staff safe. The
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protocol would constantly change; sometimes day to day. Staff were split with feelings-

some willing to jump right in, others took the LOA that was offered at the beginning of

the pandemic. Staff members would do research and at times cause panic to arise in staff

that were not as fearful in the beginning. Our Medical team at the top was not confident

in the practices provided by the CDC and would at times scare the staff. We did not run

out of PPE, but it did become an issue to have it stored where we normally did. Our

Central Supply had to lock up our N95 masks and surgical masks so they would not be

taken by staff and brought home instead of being here, where we need them to care for

the patients. Education was a big thing. With things changing so frequently, there were

“huddles” conducted to make sure everyone had the same information and felt

comfortable coming to work and caring for our patients. The staff that could do their

work from home, did. We did section off a specific area of our 40 bed hospital at the end

of a hallway close to an emergency exit to allow positive COVID-19 patients to receive

in-room therapy and have a single nurse and tech per shift that was FIT tested and would

be exclusively caring for them so we did not spread infection throughout the hospital. In

the event that it did spread, this hallway could be closed off from the rest of the hospital

and be a “Quarantine unit.” When the weather permitted, patients did therapy outdoors so

they didn’t feel so isolated. Luckily, we are a one-floor hospital, so we conducted

window visits so families and friends could still visit and talk on the phone or face time

with the patient close.

2. This is a constant change with strict guidance from the CDC and local Health

Department. When the other hospitals in surrounding areas were stopping visitation, we

followed suit. When numbers seemed to drop, we allowed 1 visitor for the entire
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admission and they could only stay in the patient’s room for a half hour with a mask on.

This went back to no visitation when the numbers spiked around the holidays again. To

slowly introduce visitation back into the facility, we had a scheduled half hour visit with

one family member in a front office that was not occupied by anyone. It would be

cleaned terminally in between each visit and there were only 3 visits scheduled per day.

This was communicated with the front desk, the medical team, myself, the charge RN.

Window visits and calls were still offered to all. We have single rooms, so preventing

cross-contamination continued business as usual, just increased surveillance on proper

hand hygiene and donning/doffing PPE. Close monitoring of wiping face shields and

glucometers, etc.

3. Absolutely! There were changes in process for patients who would “code” as we would

only allow 2 people in the room at that time; the recorder would wait outside the door.

The door would be shut so they had to listen closely and the staff would have to shout for

the recorder. The time to get into the room was delayed for proper donning PPE and the

process changed for the patient as well. Personally, I have seen a lot of therapy

limitations put on for the patients in the beginning for recovering patients. They were not

allowed out of the room for therapy in some cases. A lot of arguing and animosity

between myself and members of the medical team as I was advocating for the patient to

receive the therapy they were here for. Some staff continued to treat the patient like the

infection and not a person.

4. I think we all have accepted an unwritten responsibility to hold our peers accountable for

their lack of proper ppe, hand hygiene, education, etc. We see staff that normally are not
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in the clinical areas helping if they can to clean door knobs and reporting things they see

to me if it seems to be an infection control issue so I can educate.

5. There have been some barriers. Some facilities were reluctant to take patients if they

knew they were once infected. It was hard to get some patients the home health care they

needed due to short staffing in the home healthcare field. Liaisons were unable to do

home visits or see the patients to get an accurate picture of what the patient needed as far

as therapy, so some of the discharges were to SNF for more rehab. Some had longer than

normal stays here.

6. I am also the Wound nurse for the facility. We have seen many pressure ulcers that were

directly related to the pandemic, adequate staffing, positioning in the ICU, nutrition, etc.

Most were stage 3 or 4; needing to have surgical flaps or wound vacs applied. The pain

would lessen their tolerance for the three hours of therapy needed a day. Some were

unable to sit, stand, use a slide board, even get out of bed for periods of time. Some as

young as 23. Psychological issues have also increased due to the isolation.

7. We have seen so many patients in that population that are still fearful of dying due to

COVID-19. Some do not want to be in a hospital setting, some delayed care going to an

acute care facility because they did not want to contract COVID-19. Many have

nutritional deficits that we are still battling because all of their calories are going towards

healing a wound instead of giving them strength to do their therapy.

Response 3: Jessica Loller BSN, RN

Transitional Care Nurse

Christiana Hospital
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1. COVID-19 has impacted Christiana Care Hospital Services in most aspects of nursing. In

2020, when the pandemic first hit, all of the areas with negative-pressure rooms were

designated specifically for COVID patients; this was the majority of the E-Wing. Other

specific units for patients that did not require the assistance of a ventilator to breathe were

also set in place. If a patient required the assistance of high flow, CPAP, or Bipap, the

patient required to have an “Air Scrubber” which is a specialized air filter to clean the air,

which were not always in stock. I remember a specific moment where there was a

hospital-wide shortage of PDI disinfecting wipes, and upper management came around to

collect them all from our units leaving us without a way to disinfect our scanners,

hospital phones, dynamaps, and stethoscopes that were contaminated in patient's rooms.

The solution to this that came from upper management was to use soap and hot water

where applicable for disinfecting purposes. Among not being able to disinfect our

different devices, hospital shortages also included: PPE that was low and rationed out,

N95’s that were hard to come by, we were told to re-use a single surgical mask for

multiple shifts in a row, nursing staff was low, patient care technicians were card to come

by, and on top of these shortages with the surge in the virus cases additional patients were

added to our assignments sometimes leaving unsafe nurse-patient ratios. Now things are

finally improving but we have new issues like 1 mL syringes and 22g needles because

they get diverted to vaccination sites.

2. Due to the surge in COVID, patients have been forced to be without the option of visitors

and family at bedside. This has been especially difficult on patients, families and hospital

staff for the patients who are suffering from COVID and on their death bed. Families are

unable to see their loved one in person and have either had to see them on a screen as
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they take their dying breath or unable to reach the family at all and patients die alone. In

the beginning, visitors were strictly prohibited from being able to come in to the hospital

at all. Ipads were used to communicate between patients and families. Visitation rights

were slowly returned for patients that did not have COVID but were made hospice or

actively dying so that family could be with their loved one as they passed away.

Sometimes confused patients can have a visitor for a short time if it helped them with

dementia or similar issues, because they rely so much on consistency to cope. A lot of the

decisions about visitors were put on the nurse on shift, and that just added more strain if

one nurse said no but another said yes. Visitors were asked to wear masks at all times.

During the pandemic, COVID patients that did not require a Negative-Pressure room

were cohorted together to preserve and make room for other patients. Nurses that are

providing care for COVID patients have been given the proper PPE to be able to care for

this patient population, although sometimes it is not enough to keep the nurses from

becoming sick themselves. There have been instances where patients have come up from

the ED (which has been swarming with the virus contaminating the other patients who

are patiently waiting to be seen) who either were not tested or did not show any signs or

symptoms of the virus and come up to other floor beds for treatment only to find out in 4-

5 days' time that they are developing symptoms of covid and have contracted it from the

ED. The nurses taking care of this patient who are only wearing surgical masks have now

been exposed to the virus and have fallen sick because of it leaving staffing shortages all

over the hospital.

3. From a patient perspective, barriers and limitations to patient care include but are not

limited to: lack of family support in healing, lack of proper medical care in regards to
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being on the incorrect floor due to bed unavailability or increased nurse-patient ratio

spreading nursing care very thin, shortage on ventilators requiring nursing care to become

creative in ways of oxygenating the patient, increased anxiety and fear in the patient for

being in a hospital and needing healthcare. From a nursing perspective, barriers and

limitations to patient care are all of the spectrum from lack of supplies, proper PPE, staff,

increased nurse-patient ratio, and decreased detailed nursing care due to increased patient

load. Halfway through the pandemic, management sent out an e-mail modifying nursing

care saying that we could do focused assessments instead of head-to-toe assessments if

our patient load increased. There was also the possibility of working in a tiered model

where a nurse and a PCT/SNE would be a team in order to be able to care for more

patients at a time. Thankfully, this was not something that happened on my floor, but it

did happen on other units.

4. See above. Tiered model (RN + PCT/SNE), focused assessments vs. Head-to-toe. No

longer having to do care plans (paper and electronic) every night. Most nights we run

short on nurses and PCT’s, so increased workload across the unit.

5. Barriers to discharge include needing a covid surveillance test before discharge to a

facility, waiting at the hospital for beds to become available at facilities, and patients

being forced to take beds at a facility that are not their first choice because of availability

impeding their recovery because the facilities are not as good.

6. There has definitely been an increase in patient harm due to the pandemic. Nursing

shortages are everywhere, including facilities that take vents that are not very good to

begin with. Patients come in dirty, unkempt, in their own filth, yellow scales on their feet,

unstageables and stage IV pressure injuries to their bony prominences, Dale collars that
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hold their trachs that have not been changed in weeks creating skin breakdown around the

neck. There are not enough nurses to care for these patients at the facilities so the patients

don’t get good nursing care, or care at all and deteriorate quickly. I have also had a

number of patients or their families ask me for help in registering for the vaccines. They

express so much frustration with waiting lists or trying to understand the websites for

registration, and there are limited resources to help them. I see it more with the older

population, especially those who might not have needed to learn computers for their jobs.

They are the ones that struggle the most. But over the phone with family members there

is only so much I can do. I have even had former patients reach out to me on social media

trying to get help. It isn’t the best system and I can understand their frustrations.

7. Most older people are so terrified of contracting the virus that they will wear their masks

and follow the rules. I have seen covid patients that have recovered come through my unit

and have multiple long-term effects such as needing oxygen, needing rehab for being

deconditioned, heart problems, even neurological problems, not being able to come off

the ventilator and breathe on their own, etc. Challenges include not being able to go back

to their normal life before they contracted the virus, and adapting and living with the new

chronic illnesses that have come from contracting the virus, which not only plays a

negative impact on their physical health but their emotional health too. I have also seen

patients wait longer than they should have to be seen by a doctor because they were

afraid of coming to the hospital for treatment.