As the sun would begin to rise, the typical day started by treading though thick gravel and bypassing two guard gates to enter into the Monrovia Medical Unit in Liberia. Once inside the gate, scrubs and rubber boots were donned and the journey for caring for suspected and/or confirmed Ebola patients began. Obtaining the nursing report from the previous shift was a normal process. However as charge nurse, initiating a plan of care for the patients during my shift required modifications. A nursing care plan was a must, although the team realized the standard “nursing care plan” as we generally knew it required a shift in thinking.
Historically, nurses have used care plans to aide them in their direction of patient care. A nursing care plan generally outlines a set of actions the nurse will execute to aide in the resolution of or planning of patient care. It is a holistic focus and is based on specific nursing outcomes that are realistic and deliberate. Additionally, the care plan has expected outcomes, goals, and nursing interventions.
Care Plans for Ebola Patients
Determining how to use a nursing care plan effectively on an Ebola patient posed a few challenges. The first challenge was learning and determining the type of care required for Ebola patients. The next challenge was remembering you would need to decrease the amount of time and amount of physical contact you could have with the Ebola patient. Touching was only done if absolutely necessary; otherwise a distance of at least three feet should be maintained. Incorporating multiple disciplines into the plan was also a challenge.
When caring for suspected or confirmed Ebola patients, full personal protective equipment (PPE) must be worn. This includes a respiratory, Tychem suit, rubber boots, two pairs of gloves (minimum), a hood, a surgical mask to cover the respirator, googles, and an apron. Movements in the full PPE must be slow and deliberate. The amount of time in which one could remain in the full PPE varied from one treatment unit to another. Strategic planning was needed before the staff was allowed to move into the patient care area. Due to the amount of planning, preparation, and time constraints that must be taken into consideration when caring for the Ebola patients, the theory of a nursing care plan was replaced by a “dive plan” at the Monrovia Medical Unit in Liberia.
Diving Into Patient Care
So what exactly is a “dive plan”? Imagine a scuba diver and their plan to dive. They require certain gear such as a dive suit, fins, oxygen tank or other breathing apparatus, diving mask, and dive lights. They have to determine the amount of time they can stay under water, what their main objectives are as they enter the water and how much time each objective may take. Thus they have a “dive plan” to increase the probability that a dive will be completed safely and the goals are achieved. Dive planning also allows them to ensure the divers have the correct competency/skill set to accomplish the task.
When caring for the Ebola patients, we took a huge risk with diving into the patient care area which was secured by some mechanism such as fences, gates, or ropes. Like scuba divers, the team that prepared to enter the Ebola patient area must have the appropriate gear, skill set and plan. To illustrate an example of what a dive plan may consist of, first imagine taking 15-20 minutes to properly apply the full PPE.
The dive team may consist of two nurses and a safety member who will monitor the safety of the staff. It could also consist of providers, a nurse, a safety member, and two lab technicians for example. Each team member would have a designated role and very specific assignments, such as taking vitals, performing nursing and provider assessments, administering medications, providing patient care, assessing the safety of the team members, running lab values, emptying trash, and emptying the bedside commode.
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Sticking to the Plan
Although these tasks may seem pretty simple, consider executing the dive plan and not being able to deviate from what is written. For example, if a patient needs to have their linens changed and it is not on the dive plan, it cannot be done during that dive. The change would have to be done on the next dive which could potentially be a couple of hours away. If all of the tasks on the dive plan could not be accomplished during that dive, the tasks would be transferred over to the next dive plan. The dive plans were very rigid and once they were approved and signed by the charge nurse or chief nurse and the safety chief, they could not be changed.
Traditional nursing care plans work well, provide a sense of comfort to the patient, and a sense of direction and accomplishment to the nursing staff. The rigidity of a dive plan sometimes limits and often times leaves a nurse feeling as though he/she has not fully accomplished their job as a nurse. When drafting a nurse care plan in a regular hospital setting, be grateful of the opportunity to include as many items on the plan as deemed necessary. Be grateful for the opportunity to have the patient see all of you and not just your eyes staring at them through a pair of googles. Additionally, be thankful for the opportunity to touch a patient’s skin or even give a patient a hug if needed.
Although a dive plan is necessary and works well for rendering care to an Ebola patient, it can often be emotionally challenging for both the patient and the team.
Stacey Barley is United States Public Health Service Commissioned Corps officer who was recently deployed in Liberia.