Nurses are the backbone of all of the health care professions: we care for people and communities in difficult situations. We are compassionate and ethical. We put ourselves at risk daily for everything from violence from patients and families to contacting contagious diseases to post-traumatic stress from what we witness.
Here is some of what I have read about on the social media COVID19 for nurses and healthcare providers pages that are popping up faster than dandelions.
- There is poor planning by, and a lack of communication from, most hospital systems, likely in part impacted by the lack of leadership at the state level. A national survey of nurses by National Nurses United found “high percentages of hospitals do not have plans, isolation procedures, and policies in place for COVID-19; that communication to staff by employers is poor or nonexistent; that hospitals are lacking sufficient stocks of personal protective equipment (PPE) or are not making current stocks available to staff; and have not provided training and practice to staff on how to use PPE properly”. https://www.nationalnursesunited.org/press/survey-nations-frontline-registered-nurses-shows-hospitals-unprepared-covid-19
- Personal Protective Equipment is now rationed. In inpatient settings, some nurses are asked to use just one mask/ day. An article in the New YorkTimes details how nurses are begging for PPE: https://www.nytimes.com/2020/03/05/us/coronavirus-nurses.html
- In the home care settings, nurses are asked or told to use one mask and one gown/ day. Obviously, this means they can’t maintain or implement proper precautions when traveling from house to house, the gown itself potentially becomes a contaminant.
- In the home care setting, patients are canceling appointments because they view the nurses as vectors. In the long run, this could have huge implications for greater levels of care needed by these patients if they decline without proper care and guidance.
2. Most facilities do not have plans in place for the forthcoming surge in COVID19 patients.
3. The Centers for Disease Control rolled back the N-95 mask requirement and has stated that a simple surgical mask is sufficient in caring for COVID19 suspected or confirmed patients, and that may be used for extended periods while caring for multiple patients. They also have decided that reusable gowns are fine to use. https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers
4. Fears of getting sick themselves are rampant amongst nurses and other providers. Pregnant nurses have no idea if a COVID19 infection might affect their pregnancy. Those nurses with existing health conditions who are at risk are not sure if they should come into work, or reveal their health conditions to the workplace, or risk losing their jobs. Additionally, nurses who come home to care for elderly relatives, children, etc. are petrified of making them sick.
5. Nurses are not offered COVID19 testing, and if they have symptoms, they are often being told to use vacation, paid time off, or leave without pay, and to self-quarantine and contact the workplace in 14 days. Those who are at risk are not identified quickly. https://www.theverge.com/2020/3/5/21166088/coronavirus-covid-19-protection-doctors-nurses-health-workers-risk
6. Nurses may be mandated to work overtime, which can wreak havoc on stress levels and immune responses. https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers
The CDC and NIOSH recognized years ago that working 12-hour shifts alone may be dangerous, with deteriorating performance on psychophysiological tests and an increase in risk for injuries. Poor outcomes and personal capabilities worsen with 12-hour shifts worked particularly in combination with working more than 40 hours. Working overtime obviously leads to physical fatigue, and it also increases risks for alcohol use and cigarette smoking. And there is still a lot we don’t know, such as how does working longer impact women or older workers? What about those with pre-existing or chronic conditions? What is the influence of occupational exposure?
What can we do, and what are nurses doing?
Now is the time: we are going to have to advocate for ourselves. We also need to demand proper access to PPE, PPE training, proper testing approaches, and call for OSHA standards related to the risks we face.
- The Ohio Nurses Association is advocating for the availability of more PPE: https://www.wvxu.org/post/ohio-nurses-advocate-additional-supplies-prevent-spread-covid-19#stream/0
- The National Nurses United is calling for our health care systems to dramatically ramp up hospital readiness instead of rationing: https://www.nationalnursesunited.org/press/nurses-time-sharply-ramp-health-care-capacity-covid-19
- NNU also has a recording you can listen to gather more information and consider the next steps: https://www.nationalnursesunited.org/covid-19.
- The ANA and the American Hospital Association have requested more funding to help support efforts: https://www.modernhealthcare.com/safety-quality/qa-ana-president-advocates-readiness-fighting-covid-19.To download the letter, visit here: https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/corona-virus-letter/
- On March 11, the ANA sent a letter to Mike Pence asking that nurses be consulted around major policies developed to address COVID19, flexible licensure and telehealth are enacted to ensure adequate staffing in hard-hit areas, and that federal sick pay leave be granted for all healthcare workers quarantined due to exposure or contracting COVID19 in the course of their work. https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/corona-virus-letter/
- On March 12, the ANA called for congress to require the CDC provides data-driven transmission science behind the decision to change the masking requirements toward less protective measures. https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/corona-virus-letter3/
- On March 12, the ANA, AMA, and AHA contacted Mike Pence to declare a national emergency/ disaster to enact the Stafford Act. The Stafford Act would allow for an orderly and systematic federal response when states are overwhelmed. https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/corona-virus-letter-AHAAMAANA/
- The Stafford Act was enacted, though historically it is rarely used for public health disaster issues: https://www.forbes.com/sites/mattperez/2020/03/13/the-stafford-act-invoked-by-president-trump-has-rarely-been-used-for-public-health-emergencies/#98543831fd32
- The Emergency Nurses Association has a plethora of information: https://www.ena.org/practice-resources/covid-19
We can all act as advocates locally to call for safe working conditions, and we can join forces with our national nursing organizations to continue to call for support, funding, and access to proper PPE.
Feel free to share your ideas here.
NurseManifest 
Hi Carey
Yes, it is a very difficult situation and about to get much worse.
Being the not very well closeted, logical positivist in the crowd, I have been following this since the earliest reports. Over the last couple of weeks I have had extensive email conversations with statisticians in the UK, in which we have been sharing analyses and trying to anticpate growth rates.
At the moment we know that there are many more cases out there than testing has revealed. There is much disagreement as to how this affects measures of lethality: Is Covid-19 about as lethal as the flu, as some very misinformed people like to put forth. Is it 5 times more lethal than the flu? 10 times? 30 times?
I’d guess it will settle somewhere between 5 and 20 times more lethal but that is heavily dependent on the measures taken.
Here in the US, we have virtually no Federal response. In China they suarantined a dozen Chinese cities (60,000,000 people) and delivered food to people.
Clearly, we have not done that here. Worse still, as I have been saying for the last 10 days, we had a few hundred thousand bikers congregated in Daytona Beach, FL for Bike Week, having travelled from every corner of the country, and the planet, and crammed into overcrowded housing, hanging out in crowded bars, and actually trying to prove their macho by disregarding the warnings from the CDC. Those few hundred thousand bikers are now engaged in one of the largest migrations of human beings, spreading out across the country, and the world. The first case of Covid-19 in Volusia County FL was reported the morning of the first day of Bike Week.
While we clearly don’t know how many cases are really out there, it does seem as though the exponential growth curve is such that the number of cases is doubling about every 3 days. If someone wants to know what that looks like I will be glad to explain.
A subtelty of my work on Professional Caregiver Insurance Risk, is coming to light at the moment. Physicians, among other health care providers, who accept capitation-like health care finance mechanism, are their patients’ de facto health insurers. Physicians who get paid monthly, whether patients come for care or not, are now either closing their practices, or restricting hours, and turning people away who are sick and asking them to go elsewhere. That is the equivalent of getting a formulaic denial of claim letter from your health insurer. While their actions are correct in a fee for service payment system, it is malpractice, and fraud in the health care finance system we actually have.
We also have a health care system that has never felt the need to provide health care for all Americans. Between 20 and 50,000,000 people don’t have their health care needs met under normal circumstances, so it is no surprise, that a system that has been on the brink of collapse for decades is goingto fail us in the absence of a miracle. If we had a national health insurer, as I have advocated for decades, those Americans’ needs would have been getting met all along and our health care system capacity would be closer to what we will need the next 3 months.
In my dissertation, in 2004, I described a shift in hospital procurement patterns that I found alarming back in 2003 when I first learned about it. Major hospitals were no longer getting supplies from locally based intermediaries, but ordering supplies, sometimes from more than 100 miles away, because the supplies were cheaper by fractions of a penny per dollar. It was clear to me as soon as I learned of that, that there would come a time when those fragile supply chains would fail. We are now there.
While exponential growth models are appropriate at the current moment in terms of anticipating the demands that will occur in the days and weeks ahead, the long term situation is a little different. Barring Draconian measures to spread the Coronavirus, the entire population of the country would likely have become infected within the next 60 days. Barring significant mutations (I am not all that confident about this) there will be no new cases after that point. So in reality, because it gets more and more difficult to infect health people when there aren’t many healthy people left, the infection rates will likely start declining in 3-4 weeks – that is just plain old mathematics.
In China, the death rate, to diagnosed cases, is 4%. But that is because China quickly ramped up their health care capacity, building several thousand bed hospitals in less than 2 weeks. They were also able to move equipment, supplies, and personnel to those new hospitals. Had they not done that, the situation we are in at the moment, their death rates would have been much higher.
We have not, and likely cannot emulate, the performance of the Chinese. It is inevitable, again assuming the absence of a miracle, that our marginal capacity will be sufficient for the coming wave of patients. Triaging of patients will lead to elderly people, particularly those with co-morbidities, to be denied intensive or extensive care. Thus far about 80% of people appear to have mild symptoms, 15 percent require hospital based care and oxygen, and about 5% require intensive levels of care, including respirators, and that care will likely take quite a while since we don’t have an effective pharmaceutical remedy at the moment.
In China, because the disease itself was not well understood, and because it swamped system capacity and resources, many Chinese doctors and nurses died. Here in the US, I have had contact with many woefully ignorant nurses who believe what donald trump says, and they have practiced, and encouraged their patients, friends, and family members, to treat this like a normal flu event. I was about to start working in home health myself, and I asked the director of the office to hold the weekly staff meeting outside last week. I was ignored, and I chose not to attend. The reality is that many new home health patients come out of the hospital without clear details about their needs. We will absolutely see some Covid-19 patients coming out of hospitals, to their homes, and into home health care without Covid-19 diagnoses attached to their records. As well, the supply closet at the agency was bare two months ago. The practice at that agency is that each nurse orders their own supplies, which are then shipped in by the cheapest supplier available. As for hospitals above, it is a system designed to fail.
Grocery stores are yet another looming hot zone. Grocery store personnel come in contact with more people than nurses, many of those customers are coming in for OTC medications to deal with symptoms of illness. As a result, there will likely be clusters of cases for grocery store employees and grocery stores may find it difficult to continue operating. Fear of infection and illness will take a toll on their operations and that, in turn, will impact the availability of basic necessities.
I could go on… There will be food shortages, supply shortages, staff shortages in critical industries… I hope I am wrong about some of these projections, but I have been anticipating this scenario for decades. As I said in the aftermath of 9/11, the only reason the NYC health care system didn’t fail was because almost everyone affected died rather than being injured.
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