Learning from Experience—Mistakes and Successes in Caring for COVID-19 Patients

Patricia Benner, R.N., Ph.D., FAAN
EducatingNurses.com  June 3, 2021

The COVID-19 Pandemic confronted healthcare workers at all levels with a new disease fraught with uncertainty, unknown pathology, uncharted trajectories with high acuity, and mortality rates, especially in older age groups. Common clinical trends, signs and symptoms, sequelae, best treatments, prevention, and intervention strategies, and more, are still yet to be determined. To say that this caught clinicians, used to caring for patients using Evidence-Based Guidelines off guard, is a huge understatement. Care of COVID-19 patients was characterized by untested assumptions about similarities with other respiratory illnesses, other kinds of influenza illnesses, and ongoing emerging new neurological and other clinical manifestations of this new disease. Rationing guidelines for use of lifesaving equipment were based on what was known about other respiratory diseases, creating missteps based on unfounded assumptions.  Fins  (2021) articulates this navigation between surety and doubt when confronting clinical decisions for patients with COVID-19:

This alliance, between surety and doubt, has been disrupted by the pandemic. Faced with critically ill patients with a heretofore unknown (and deadly) pathogen and obliged to provide care, experienced clinicians will question what they know and the state of available knowledge, reverting to the epistemic ambivalence they experienced during their professional training. The clinician’s developmental regression is made all the more frightening by fears of contagion, their own mortality, and the safety of their family (Fins, 2021, p.74).

Fins (2021)  goes on to point out that many mistakes were made due to acting with very limited knowledge about timelines and possibilities for treatment and survival for COVID-19 patients.  J. Fins’ article, is a “must-read” to learn about where we went wrong treatment and rationing decisions about COVID-19 patients and points to what can be improved in current and future care of COVID-19 patients. He lays out the following account of where guidelines and decision-making went wrong.

COVID-19 patients were assessed using the Sequential Organ Failure Assessment (SOFA tool), a periodic reassessment of the assessment tool to determine whether it was effective/beneficial to continue the use of the respirator. These assessments occurred at 48 and 120 hours after initiation of ventilator treatment to determine whether ventilator use should continue. After 120 hours, patients were to be reconsidered every 48 hours. However, it was discovered that these timetables did not allow sufficient patient recovery times for COV19-19 patients, and if the SOFA Guidelines were followed, “tragic choices” if premature removal of COVID-19 patients from ventilators who would recover if left on the ventilator:

The guidelines were never implemented for many reasons, among them the political toxicity associated with questions of triage. But here I focus on another reason, one that is rarely considered in discussions of medical science and its application to the mission of saving lives and alleviating suffering: the dual nature of time. The interplay of time, knowledge, judgment, and action is an essential determinant of how science works in the real world. The ethical application of what we know to what we do depends on understanding this interplay.

In retrospect, the source of our error in seeking to apply the triage guidelines to COVID-19 was obvious, but the implications of the misunderstanding are obscure. The assessment schedule in the ventilator allocation guidelines was designed for pandemic flu, not the coronavirus. It was a classic case of analogic reasoning gone astray. Pandemic flu had a much quicker course than COVID-19, and the time frame for periodic reassessment for the former was ill-suited to the latter. COVID-19 patients needed much more time on the ventilator to declare themselves as beyond cure. For some patients who were sedated while intubated, there came an atypically long period of reversible unconsciousness. It wasn’t a matter of hours but weeks or even a month before extubation was possible. Their pace of recovery was more akin to the trajectories of patients with severe structural brain injury and disorders of consciousness than an infectious disease. (Fins, 2021, p.73-74).

Analogic reasoning, as Fins points out can’t work when the actual comparisons with the new disease cannot be known, and thus, are unreliable. All health care educators and clinicians would do well to heed the humility of physicians dealing with unknowns amid this novel pandemic and extend Fins’ articulation of what went well and what went poorly in the care of COVID-19 patients (Berlin, 2020). Physicians and healthcare workers were learning about this novel disease that bore little resemblance to other respiratory viruses. As Fins notes:

Time helped to transform a diagnosis into a prognosis, which is essentially a forward projection of a diagnosis over time. One notable example of this evolution was the strategy of early intubation of patients who appeared to be at imminent risk of respiratory collapse. Patients with falling oxygen levels and respiratory muscle fatigue have been traditionally candidates for immediate intubation and mechanical ventilation because these signs indicated impending respiratory failure, a life-threatening emergency. But curiously, many COVID-19 patients tolerated these stressors and were able to avoid intubation, especially if aided by noninvasive positive airway pressure devices used to treat sleep apnea, and by proning (having patients lie on their stomach). Indeed, growing clinical experience showed that patients who were quickly put on mechanical ventilators fared less well than those for whom such treatment was either avoided or delayed. Aggressive care, which had been life-saving for other, seemingly analogous conditions in the past, turned out to be potentially counterproductive. So, over time, we had learned two very different things about COVID and about time that challenged our former understanding: first, that delaying ventilation was often desirable; second, that if ventilation became necessary, it might be needed for much longer periods than for other diseases. (Fins, 2021, p. 76)

Fins’ description of the turning around of past beliefs and expectations and expectations is the hallmark of experiential learning. With well-established injuries and diseases, we expect new knowledge to come from formal research, however, with new diseases such as COVID-19, front-line clinical knowledge development from experiential learning and articulation of that knowledge comes first, by urgency and necessity, directly from experiential learning from the care of patients,  since formal research studies take time. Experiential learning from the care of COVID-19 patients early on was essential to improving their care as Fins (2021) points out.  Focus on experiential learning during complex emergencies, novel situations, and operations are a highly valued resource for learning and practice improvement in High-Reliability Organizations (HROs) that operate in novel, complex, highly variable situations, and consequently, depend on front-line experiential learning for practice improvement. As a neonatologist, Dave van Stralen, who operates in a rapidly evolving field with complex risks and high variability, (van Stralen and Tom Mercer, 2021), the attitudes and skills of front-line experiential learning of High-Reliability Organizations are required. Standardization, in such rapidly evolving care, is not safe nor reliable. These authors consider every opportunity to learn from success and failures in saving a premature infant’s life as a source of knowledge for improved outcomes for the care of current and future similar premature infants (van Stralen & Mercer, 2021). Fins (2021)  also calls attention to the essential learning from uncertain, fast-moving unpredictable situations such as the care of COVID-19 patients:
Medical progress depended upon the passage of time, with inquiry occurring through structured research and, more often, clinical practice—what the American philosopher and pragmatist John Dewey described as experiential learning by doing. Time became a balm for the uncertainty bred of ignorance, or at least for some of it. It provided an opportunity to make sense of one’s clinical observations and experiential learning and transform a disorganized set of novel findings into more coherent insights that would improve patient outcomes. (Fins, 2021, p. 75)

COVID-19, being a novel virus was initially undescribed. Clinicians were faced with unknown trajectories, trends, treatments, and likely outcomes, leaving them to draw unfounded assumptions about similarities and contrasts with other clinical conditions. But clinicians did learn almost daily, experientially through confronting unmet clinical expectations with COVID-19 patients who differed from other patients with typical respiratory ailments.

“The clash between a mistaken old belief and an updated belief would seem to be a form of dissonance…The more you engage in dynamic reasoning [processes], the less chance there is for dissonance between the old belief and the updated, [improving] belief to develop, the fewer errors you make, but at risk of a new set of cues being neglected. Karl Weick (personal communication) motor cognition is how we understand our movement and how movement helps us understand the events. (van Stralen & Mercer, 2021 p. 98)

Through “motor learning” (situated embodied motor learning), physicians and many front-line health care workers relied increasingly on their direct observations of what helped and hindered the recovery of COVID-19 patients, i.e. direct experiential learning from clinical practice. Clinicians took notice and communicated their front-line observations (Fins, 2021; van Stralen & Mercer, 2021). We can learn much from studying High-Reliability Organizations (HROs; Weick & Sutcliffe, 2015) who have high reliability even though their work environments and nature of their work are fast-paced and unpredictable. Standardization and lack of variability do not lead to the high reliability of such organizations (Weick and Sutcliffe, 2015). Healthcare is often highly variable, unpredictable, complex, especially with novel diseases such as COVID-19 and rapidly ongoing improvement of care such as in the care of premature infants, as van Stralen and Mercer (2021) point out.

Fundamental differences for decision-making in liminal environments and stable environments lie in the purpose and function. Decisions and actions have the purpose of generating information. Even unwanted results are information with meaning and relevance…For the HRO, “error” has functions to identify boundaries of performance and operations, the “envelope” that HROs seek to expand. “Error” identifies a mismatch between what is known and what is uncertain or ambiguous. “Error” identifies unexpected or unrecognized changes in conditions or the environment. The authors (van Stralen and Mercer, 2021), coming from operational environments, had not encountered the everyday use of error for operations. This makes sense because, in the operational environment, we do not know what works until we act. One cannot find solutions by reasoning. One cannot organize or build a structure from the outside. We must enter the problem, thus becoming part of the problem (van Stralen D., 2020). ( van Stralen & Mercer, 2021, p.97)

This observation by van Stralen and Mercer that engagement with the problem is crucial to solving highly changeable and high-risk situations is similar to research findings (Benner, Tanner, & Chesla, 2009; Benner, Hooper-Kyriakidis & Stannard, 2010; Dreyfus & Dreyfus 1988; Dreyfus H.L., 1988) that found that skills of engagement in the problem and interpersonal situation are essential to expert performance. Both problem and interpersonal engagement support curiosity, attentiveness, attunement, openness, and responsiveness to ensure that the person notices when things do not go as anticipated and consequently learns from those failed expectations.  Experiential learning typically results when expectations aren’t met and outcomes do not match predictions. Experiential learning involves a turning around of preconceived notions or pre-understanding of the situation at hand (Gadamer, 1991; Dreyfus & Taylor 2015). With a novel disease such as COVID-19, frontline experiential learning prompted by attentiveness, humility, and curiosity about puzzles, unexpected changes in the patient’s condition across time were essential to saving lives and practice improvement in the care of COVID-19 patients.  Such frontline experiential learning forms the basis of knowledge development that fosters improvement in the care of patients for this relatively unresearched disease, just as it does in the novel, complex problems encountered by HROs.

Nurses are essential front-line workers during this COVID-19 Pandemic. Nurses had to innovate daily to meet the novel demands of caring for patients with COVID-19 where disease, trajectories, and treatments were not yet known (See: EducatingNurses, New York Times: Seeing Death through a Nurse’s Eyes  February 26, 2021, by Patricia Benner).  Nurses devised telecommunication between patients who could not be with their loved ones and patients who were critically ill and often dying. New graduate nurses were often assigned to care for COVID-19 patients with little or no specific nursing school preparation. Nader, Hedenfeldt & Timmons (2021, p.386) reported in an article entitled:  Novice Nurses’ Experiences Caring for Acutely Ill Patients  the following seven problems most frequently mentioned by the new graduate nurses:

  1. Dealing with death,
  2. Which personal protective equipment (PPE) will keep us safe?
  3. Caring for high acuity patients with limited training,
  4. Difficulties working short-staffed,
  5. Everything is not okay,
  6. Support from the healthcare team,
  7. Nursing school preparation for a pandemic” (Nader, Hedenfeldt & Timmons (2021, p.386),

In addition, new graduates reported that they had not anticipated caring for so many dying patients:

“So most of my patients with COVID die. So if they’re in the ICU,

they don’t leave the ICU alive. So, I think that’s a big fear, just knowing I’m the last person to be there with them because most of them don’t make it.”

Participants described being greatly impacted by each passing, but after a while, they could not recall each patient in their care who had died. Irena put it this way:

 “The amount of loss that I’ve seen since March, at

first it was always in front of my mind. I would say, I’ve lost four patients so far, I’ve lost six patients so far and now the sad truth is, I can’t even keep track anymore.”

Emma noted that even her experienced nurse colleagues had never experienced so many deaths,

“A lot of the nurses that I worked with have literally never experienced a death, even in five or six years of nursing. Now we’re seeing it every shift so it’s a big adjustment for us. We’re used to having patients have good outcomes (p.386).”

Being immersed in the care of the dying is central to the care of COVID-19 patients, and new graduates were unprepared for the responsibility and suffering such care involved (Nader, Hedenfeldt & Timmons (2021, p. 386; EducatingNurses, New York Times: Seeing Death through a Nurse’s Eyes  February 26, 2021, by Patricia Benner).

Caring for COVID-19 patients meant that new graduate nurses with caring for many critically ill patients; participants reported that the medical demands of COVID patients required them to pivot quickly to caring for patients of much higher acuity. As Emma stated, “the level of acuity of my patients increased exponentially overnight with no training and we just had to go with the flow and figure out how to handle it.” Many felt inadequately prepared for this transition, as Irena described, “The reality for us is that we had an ICU situation on almost every floor that we were on, so our house supervisor basically said, you’re working on an ICU unit without ICU training right now.” Nurses mentioned that managing critically ill patients is stressful for new nurses under normal circumstances, but the pandemic compounded the stress. Bill gave an example of caring for a challenging trauma patient with multi-organ system dysfunction who also had COVID, “they’re not only a trauma patient but now they’ve contracted COVID, so where they would otherwise not need aggressive respiratory support, now they’re needing respiratory support.” Nurses described an increase in daily code events and uncertainty about codes (Nader, Hedenfeldt & Timmons 2021, p.387). New graduates would ordinarily be buffered from this urgent, complex care by preceptors and available clinical nurse coaches, but in the Pandemic staff shortages precluded the usual educational support offered to new graduate nurses. Thus, the problems of caring for dying and critically ill patients were compounded by severe staff shortages which caused working extra shifts, in addition to working with fewer nursing staff than needed:

Staffing shortages were not limited to nursing but also patient care technicians and certified nursing assistants, adding to nursing workloads. As Marie noted, “We were kind of forced to take on the role of tech and a nurse with higher acuity patients. So, I think day in and day out for a few weeks there it was very stressful for those reasons.” Because of the shortage, nurse-to-patient ratios increased as did overtime requests. Participants worked extra shifts for a variety of reasons, such as wanting to help the team. Bill described picking up extra hours as “It’s exhausting. But I like what it stands for and being able to help and be there for the rest of my team and the patients.” Others worked extra, sometimes excessively, for financial incentives. Emma said, “There used to be all sorts of rules and regulations in place of how many shifts in a row we can work and how many shifts in a pay period you can pick up, but desperate times call for desperate measures, and there were no rules. Some people just did crazy things to make crazy amounts of money (Nader, Hedenfeldt & Timmons. 2021, p.387)

It will take years of clinical experiential learning from successes and mistakes before care of patients with COVID-19 becomes verified and extended with scientific studies and for the varied experiential learning from the frontlines to become commonly known and discussed and researched. Clinicians can best cope with this uncertainty by careful observation and making known what they learn daily, caring for patients with this novel disease. We need first-line description and interpretive reports, such as reported here, to develop a self-improving practice in the care of COVID-19 patients, with better patient outcomes, more informed guidelines on selection of best treatments, and wise rationing approaches along with improved, continuously updated educational preparation for caring for COVID-19 patients.  We need to keep in mind what we are learning and write about it and about what we do not yet understand.

References

 

Dreyfus, H.L., Dreyfus, S.E. (1988) Mind over Machine:.The Power of  Human Intuition and Human Expertise in the Era of the Computer. The Free Press

Dreyfus, H.L. (1988) “Misrepresenting Human Intelligence.” THOUGHT VoI. 6 1 No. 243 (December 1 986) 430-441.

Dreyfus, H.L., Taylor, C. (2015) Retrieving Realism. Harvard University Press.

EducatingNurses, New York Times: Seeing Death through a Nurse’s Eyes  February 26, 2021, by Patricia Benner. https://www.educatingnurses.com/death-through-a-nurses-eyes/

Fins, Joseph J. “COVID-19 Through Time.” Issues in Science and Technology 37, no. 3 (Spring 2021): 73–78.

COVID-19 Through Time

Gadamer, H.J. (1991) Truth and Method. Crossroads.

Naylor, H., Hadenfeldt, C., Timmons, P., 2021, Nursing. Reports. 11, 382–394. https://doi.org/10.3390/nursrep11020037 https://www.mdpi.com/journal/nursrep

van Stralen, D., Mercer, T. A. (2021) “High-Reliability Organizing (HRO) is the Extension of Neonatology during Pandemic COVID-19”  NEONATOLOGY TODAY www.NeonatologyToday.net, May 2021 pp. 97-109. 10.51362/neonatology.today/2021516597109 May 2021.

van Stralen, D. (2020) “ Pragmatic High-Reliability Organization(HRO) During Pandemic COVID-19”. Neonatology Today.2020;15(4):3-9.)

Weick, K.E., Sutcliffe, K.M. (2015) Managing the unexpected. Third Ed. Wiley.

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