Before intubating her patient, Dr. Eliotte Hirshberg FaceTimed the woman’s daughter. As another nurse stroked the patient’s head, Hirshberg held her hand and, with the help of an interpreter, explained to the patient and her daughter what would happen next. After the call ended, the nurse administered anesthesia as Hirshberg prepared for the procedure, clutching the patient’s hand the whole time.
“We always ‘lay hands on the patient’; that’s part of being in the healthcare profession,” says Hirshberg, associate director of the Center for Humanizing Critical Care at Intermountain Healthcare. “We put on the appropriate PPE [personal protective equipment], but we are always holding people’s hands.”
All sorts of healthcare practices and rules changed in response to the coronavirus outbreak. As doctor’s offices and clinics closed, the vast majority of nonurgent visits either went virtual or got pushed off. Many hospitals began prohibiting visitors except in extenuating circumstances, such as for final goodbyes or to lend extra support to patients with cognitive impairments. But healthcare workers are still making sure patients experience human connection, through physical touch and communicating with loved ones.
“One of the challenges across the country is people don’t have an inside view of what’s going on in the hospitals,” says Jade Flinn, nurse educator for the Biocontainment Unit at Johns Hopkins Hospital. “We are still delivering our best care, including hand-holding and wiping eye boogies so patients look their best, even though they can’t have visitors.”
All of this helps patients, as well as caregivers and healthcare providers, cope with the stress of a coronavirus hospital stay.
Loved ones help with recovery
Hospitalization can be inordinately difficult under any circumstance. “Being cut off from other aspects of human existence can be terrifying and stressful,” says Cheryl Woods Giscombe, a professor of quality of life, health promotion and wellness at the University of North Carolina at Chapel Hill School of Nursing. “There’s more time to worry and focus on your symptoms.”
Having support is critical for recovery, explains Hirshberg, who is also an associate professor of pediatric and adult critical care medicine at the University of Utah. The presence of family (or friends) can provide a sense of reassurance and familiarity to calm a patient’s anxiety, fear and loneliness. What’s more, involvement can help improve treatment. Family members can share information about patients to humanize them, so that they become fathers, mothers, siblings and children, rather than just patients, in the eyes of healthcare providers. They can also advocate for patients, help orient them if they are in and out of consciousness, and give the hospital staff insight into the patient’s support system, which leads to better physiological and psychological outcomes.
There isn’t much research on ICU patients, who are often unable to communicate during treatment. But some studies suggest that while patients prefer some restrictions on visitation, such as limiting visits to certain hours, they feel more supported when family members are present.
Additionally, the simple act of having a loved one hold your hand can reduce pain. “Touch calms the nervous system,” explains Tiffany Field, director of the Touch Research Institute at the University of Miami School of Medicine. It triggers an increase in serotonin, “the body’s natural antidepressant and anti-pain neurotransmitter,” Field says. “That helps the person relax, decreases anxiety, and lowers blood pressure and heart rate.”
Other research finds that massage can enhance immune function. “If you move the skin, it stimulates pressure receptors,” Field explains. “These send messages to the brain to decrease the stress hormone cortisol and increase vagal activity, the production of natural killer cells and natural killer cell activity.” These cells kill viral, bacterial and cancer cells, although the effects of massage on COVID-19 hasn’t been studied.
You don’t need a massage to experience these benefits. “Yoga, walking on the floor, holding hands — anything that moves the skin stimulates the pressure receptors underneath the skin,” Field says. Hugs may help too: In a study published in Psychological Science in 2015, when participants were exposed to a cold virus, those who got more hugs exhibited less severe symptoms.
Different but the same
It’s a concern that’s come up repeatedly in coronavirus coverage: What happens to a patient who doesn’t get to see any familiar faces, or feel the loving squeeze of a hand they’ve held before? Flinn recalls a man who was admitted for care and investigation of COVID in early March. His partner asked if anybody would be in the room to make sure the patient was comfortable. “I will be there, and I will call you right after it’s done,” Flinn told him.
“It struck me,” she says. “I assume we [nurses] will always be there and that people assume that. But during the coronavirus, many assume their loved ones will be alone the whole time.”
Instead, nurses and attendants work hard to make the experience feel less lonely: They hold patients’ hands during procedures, bathe them, and turn their bodies to prevent bedsores. “That human touch has not gone away; we’re just wearing a greater level of protection,” Flinn says. “And we’re more cognizant that when we touch something, we need to wash our hands or change our gloves.”
This not only helps patients; Field says it can also help the nurses, since touch, even through layers of PPE, has a calming effect. “The person who gives the stimulation is getting the same kind of input to their skin,” she explains.
Flinn says the physical contact makes a difference. “I feel much more connected to patients when holding their hand during a procedure or wiping their eyes,” she says. “I find comfort in being able to provide that human side.”
To replace in-person visits, most hospitals are relying on virtual interactions. “In the interest of trying to champion community health and not contribute to the spread of COVID-19, we are sensitive to the difficulty of being isolated from loved ones, and we’ve tried to create other ways to involve family in the care as a team member,” Hirshberg says. No matter the circumstances, nurses, pharmacists, respiratory therapists and physical therapists usually hold daily multidisciplinary rounds to discuss a patient’s status and make any changes to their care plan. Ordinarily, they encourage a family member to be present for this. Right now, however, some hospitals are calling loved ones instead to keep them apprised of how patients are doing and give them the opportunity to ask questions.
Some hospitals also encourage patients to bring their phones with them so they can schedule calls or video chats with friends and family. Since the critically ill may not be able to talk, Hirshberg says nurses help schedule these calls to take place when patients are awake and alert. “Just being able to visualize their family member may make a huge difference for both the patient and the family member,” she says.
For those who don’t have their phones, many hospitals have acquired tablets for patients to use. These video calls may also help with ICU delirium, a condition that can cause hallucinations, incoherent speech and aggression. “Having something familiar might be able to help reorient them,” says Jennifer McAdam, associate professor of nursing at Samuel Merritt University.
It takes a team
Whether someone is in the ICU for COVID-19 or a different reason, nurses encourage family members to stay in touch with the care team — and to trust them.
Ask how you can be an active part of a patient’s care team, Woods Giscombe says. Learn the best way to stay in touch with your loved one; make sure their healthcare providers know your name and have two phone numbers to reach you. It’s frustrating to call a nurse and hear their voicemail, but don’t be discouraged. They’re probably with a patient, and they’ll do their best to get back to you. If they don’t, call back. “We recognize this is stressful, and all of our staff is ready and willing to engage and talk with family members over the phone,” Hirshberg says.
“As nurses and healthcare professionals, we didn’t go into this as just another job,” Flinn adds. “We went into this because we want to be there to be helpful. It’s a calling and duty that we are fulfilling every day. Our care has not changed [because of the coronavirus]. We are still delivering 100 percent.”