Stephanie Todd and Helen Kerr This chapter discusses the impact of the COVID‐19 pandemic on healthcare, with a focus on the role of the clinical nurse specialist (CNS) in cancer services. The chapter will commence with a brief introduction to COVID‐19 and then outline its impact on the delivery of health services and frontline workers. There will be a reflection on the role of the CNS prior to the COVID‐19 pandemic, along with a discussion that highlights the changes to this role as a result of COVID‐19. The chapter will conclude with a discussion on the way forward for the CNS and healthcare services post‐pandemic. From an early stage, it was evident that COVID‐19 would interrupt the spectrum of cancer care, particularly in relation to delays with diagnoses and treatment disruption (Richards et al. 2020) and possible cessation of treatments. The impact on cancer care inevitably caused a paradigm shift in the role of the clinical nurse specialist (CNS), not only within cancer services but also in other areas of healthcare. The World Health Organisation (WHO) (2020) states that the coronavirus (COVID‐19) ‘is an infectious disease caused by the SARS‐CoV‐2 virus’. Initially, this was as much information as was known from a cluster of cases in China in December 2019. As the world listened to the news reports, the magnitude of the impact of this virus became apparent, as the rapid increase in the number of cases led to a distorted normality on a global scale. It quickly became evident that COVID‐19 showed no prejudice and that all individuals were vulnerable to the uncertainty of the virus and its impact. The media coverage of COVID‐19 escalated as the virus and its whirlwind nature became a stark reality and threat to everyone’s way of life. Over time, the unfolding of further information revealed why COVID‐19 was so infectious, which was due to the transmissibility of the disease as it ‘spread from person to person through droplets released when an infected person coughs, sneezes, or talks’ (National Cancer Institute 2020). To minimise COVID‐19 transmission, government restrictions including social distancing, reducing population footfall and closing public facilities were all implemented shortly after the potential destruction of the virus became evident. In the context of the United Kingdom (UK), the first official ‘lockdown’ was announced on 23 March 2020, where the public were required to ‘stay at home’ to save lives. This approach was mirrored in most countries around the globe at different times. The first author, Stephanie Todd, is a CNS for individuals with a lung cancer diagnosis in a hospital in Northern Ireland (NI). The multiple components of this role include providing care from diagnosis through treatment, symptom management and end‐of‐life care. The first author will draw on her experiences in this role to outline the impact COVID‐19 had on the delivery of healthcare services to individuals with a cancer diagnosis and their families and friends. The second author, Dr Helen Kerr, is a senior lecturer at a School of Nursing and Midwifery at a university in NI, with a clinical background in cancer and palliative care. Due to the infectious nature of COVID‐19, rapid and unprecedented changes in healthcare had to be implemented globally to survive the potential tsunami effect this virus imposed on already‐overwhelmed and fragile health systems. It was evident, with vast media coverage, that enforced continual changes in healthcare would be essential at a global, national and regional level to sustain the services provided by healthcare systems. The foresight of European and national experience of the virus supported regions to mirror changed practices such as dedicating units to help manage the COVID‐19 crisis and maintaining essential services in separate areas. These approaches were tailored to local healthcare services globally. From very early on, it was clear how these events could potentially impact patients and staff and the need to reassure patients regarding their own vulnerability to the virus with no endpoint in sight. The reassurance provided to patients by healthcare staff was in addition to staff managing and masking their personal fears, which included their own mortality. Newman et al. (2021) reported that frontline healthcare workers were more likely to report psychological burden, fear and anxiety due to increased exposure to COVID‐19 treatment and care. Professionally, healthcare workers endeavoured to be proactive in a reactive situation whilst dealing with their own personal, physical and psychological safety through the ongoing uncertainty. Staff who frequently worked long shifts with high death exposure due to COVID‐19 were reported to experience higher levels of work‐related stress, with a profound impact on their mental health (Neto et al. 2020). In the context of the first author’s area of work, two of the three main hospitals in the context of NI were designated as COVID‐19 centres. These designated centres were referred to as ‘Nightingale hospitals’ locally and throughout the UK: they were aptly named after Florence Nightingale, who was known to reduce the mortality rate of the British Army during the Crimean War and use the analysis of data and statistics to revolutionise the organisation of the British Army barracks, Victorian workhouses and hospitals (Bradshaw 2017). Two crucial aspects of healthcare during the COVID‐19 pandemic were respiratory medicine and intensive care units (ICUs), and within the first author’s area of work, these were both relocated to the Nightingale hospitals. Cancer services were affected by various changes to the healthcare system as a whole and also how cancer treatments were utilised through the pandemic in regards to the downturn of surgical services, increased use of radiotherapy and modified use of systemic anti‐cancer therapy (SACT). This resulted in the reorganisation of oncology services to continue providing essential and time‐critical modalities of treatment for an often‐unpredictable disease whilst maintaining safety from the relatively unknown virus. Unfortunately, in addition to shouldering the burden of a cancer diagnosis, patients were also more vulnerable to COVID‐19 infection. This greater susceptibility was attributed to the systemic immunosuppressive state from the malignancy itself and also was a result of SACTs: for example, chemotherapy, which is an anti‐cancer drug treatment known to lower a person’s white blood cell count, leaving them more susceptible to infection (Kamboj and Sepkowitz 2009). A prospective cohort study by Liang et al. (2020) observed individuals with cancer to have a greater risk of severe events from the COVID‐19 virus, including the need for ventilator support and higher mortality rates than those without cancer, with reports of a 39% increase in severe complications from COVID‐19 in individuals with cancer compared to those without cancer. Richards et al. (2020) describe the public’s heightened awareness of the high transmissibility of the virus resulting in a reluctance of individuals with possible signs or symptoms of cancer to present to healthcare services, resulting in a late presentation in terms of cancer diagnosis juxtaposed with the suspension of cancer screening and diagnostic services as a whole. In March 2020, in the context of the UK, the Welsh and Scottish governments announced a decision to suspend cancer‐screening programmes, followed by England and NI in April 2020 (Department of Health 2020). This was mirrored globally; Waterhouse et al. (2020) discuss the disruptions brought by COVID‐19 on all aspects of cancer control and care, including cancelled cancer screening services in the United States of America (USA). This was a concern, as long‐term survival is reflective of early screening in cancers such as colorectal, breast and prostate (Hanna et al. 2020). Understandably, the public’s priority was keeping safe and well at home. Reluctance to present to hospitals stemmed from fear of self‐exposure to the virus as well as causing a burden to an already‐overwhelmed healthcare system. With over one‐quarter of cancers reported to be diagnosed through emergency routes in the context of NI (McPhail et al. 2022) and a marked decrease in emergency department (ED) attendance, the outcome of delayed diagnoses was inevitable. Furthermore, fewer people attended their general practitioner/primary physician for conditions unrelated to COVID‐19 (Limb 2021), again resulting in missed diagnostic opportunities. Richards et al. (2020) describe a downturn in diagnostic investigations such as endoscopies, as these were classified as aerosol‐generating procedures and associated with a higher risk of COVID‐19 transmission. In Australia, investigations such as colonoscopies and sigmoidoscopies decreased by 55% between March and May 2020 (Luo et al. 2022). Macmillan Cancer Support (2020) estimate that there were 1000 fewer cancer diagnoses in NI between March and July 2020, unfortunately leading to a substantial backlog of patients. In England, UK, there was a 33% decrease in the diagnoses of early‐stage cancer during the first wave of the pandemic in 2020 (Limb 2021). Many diagnostic appointments were delayed or postponed completely as healthcare services were reduced to ensure all available resources were aimed at treating individuals with COVID‐19 (Macmillan Cancer Support 2020). The relocation of some services produced an unavoidable impact on the delivery of cancer treatments ranging from surgery and radiotherapy to the delivery of SACT. Richards et al. (2020) describe the reduction in capacity for surgery during COVID‐19 as due to the increased need for theatre space and ventilators to be used for individuals with COVID‐19. Bhangu et al. (2021) note that surgery is the main modality of cure for most solid cancers; therefore, its downturn not only had the potential to affect patient survival outcomes but also affected the use of treatment services such as radiotherapy or hormonal therapy as therapeutic modalities (Richards et al. 2020). The ramifications of these changes resulted in both physical and psychological aspects, as the risk of cancer progression or hospital admissions arising from treatment complications was not to be underestimated. Within lung cancer, it has been established that delayed surgery may lead to disease progression with tumours that are no longer operable, resulting in worse outcomes and poorer overall survival (Shankar et al. 2020). Patients attending for SACT or radiotherapy treatments were at a higher risk of contracting the virus due to the immunosuppressive side effect of systemic treatment, in addition to the frequent hospital attendances to have treatment, thereby increasing their potential exposure to the virus. Cancer multidisciplinary teams (MDTs) were challenged with often‐difficult decisions on how best to optimally manage treatment options for patients. Vrdoljak et al. (2020) describe the fear of under‐treatment bias faced by oncologists, especially in the setting of metastatic disease or adjuvant therapy. The risk versus benefit of patients embarking on treatment had to be very carefully considered on an individual basis. This was more profound for individuals with a cancer diagnosis such as small‐cell lung cancer where commencement of treatment is required promptly, as often the response and symptom relief is rapid due to the initial sensitivity of the disease to chemotherapy (Sandler 2003). In 2014, Balsdon and Wilkinson (2014) stated that the role of the CNS has continued to develop over the last two decades, which appears to be the continuing trajectory. Adopting and adapting are within the CNS ethos, and these skills were required during the COVID‐19 pandemic. Kerr et al. (2021) conducted an integrative literature review to evaluate the role of the CNS in cancer care, with their findings highlighting the integral role the CNS occupies within the MDT in supporting and developing cancer services. As far back as 2003, it has been shown that the CNS is fundamental in meeting targets in relation to prompt diagnosis and treatment (Corner 2003). The cancer pathway can often be difficult for patients to navigate, especially while psychologically managing the challenges that a cancer diagnosis may bring. Therefore, having a key worker from diagnosis to advocate and provide holistic support has proven beneficial for patients. (The key worker role is the focus of Chapter 5 in this book.) Although CNSs are reported to improve patients’ experience of care, continual service evaluation from both service users and providers is recommended (Macmillan Cancer Support 2015). A CNS has an advanced scope of practice and provides expert clinical advice and care and may also be involved in the diagnosis and treatment of a health condition (International Council of Nurses [ICN] 2020). Additionally, a CNS provides symptom management, expert and evidence‐based clinical advice and guidance to patients and healthcare providers to ensure optimal care within their specialised field (ICN 2020). The CNS role in cancer services has undoubtedly transformed, with many aspects of treatment and care formally carried out by medical staff now within the job role of the specialist nurse (Henry 2015). Nurse‐led clinics (the focus of Chapter 11 in this book) and contributions to innovations in practice are embedded within the CNS role in cancer care, and many have professionally developed and enhanced their level of assessment and review skills by achieving qualifications such as non‐medical prescribing (Henry 2015). The CNS is ideally placed to practice as a non‐medical prescriber in cancer services (Osborne and Kerr 2021). Additionally, within cancer services, the CNS is the point of contact for patients with access to the multidisciplinary cancer team. Patients benefit from this with seamless and prompt service, particularly regarding symptom management and expediting review with the oncologist if required (Alessy et al. 2022).
14
COVID‐19 and the Clinical Nurse Specialist
Abstract
14.1 Introduction
14.2 Impact on Healthcare Services and Frontline Healthcare Workers
14.3 Impact of COVID‐19 on Cancer Services
14.4 The Role of the Clinical Nurse Specialist Prior to the COVID‐19 Pandemic
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