Nurses’ Concerns COVID19: Update March 29, 2020


There is so much going on that it’s really hard to summarize all of the issues. I welcome dialog and discussion of your concerns and what you are seeing and hearing about.

Nurses’ Shifting Thinking About Duty To Provide Services

I am seeing a shift in thinking with more nurses being willing to leave their jobs as they are not adequately protected: working without adequate PPE creates harm to self, others, and community.  An emergency room doctor was fired for speaking out about his hospital’s response (US NEWS report). So these actions are not without their cost.

We are also seeing more and more healthcare workers testing positive for COVID19. What stands out to me is the over 160  healthcare workers in Boston have tested positive for COVID19 in these early days. (Boston Hospital Workers test positive) and 12 nurses in Chicago have tested positive for COVID19 Chicago nurses test positive for COVID19.

Nurses who are staying in the direct care workforce are often very frightened: they are staying because if they quit, they won’t’ get unemployment, they are fearful that they won’t find another job because they left their current job abruptly, they are the sole or majority breadwinners in their families, and they are afraid of losing their healthcare benefits. Some nurses may still feel the deep roots of historically being linked to self-sacrificing, or with links to nursing’s history of religious or military duty (I do anecdotally feel like I am seeing less of this as the pandemic crisis grows).

New Grad Nurses as a Resource: Dr. Chinn pointed out to me that one area that is not getting enough attention is the idea of new grad nurses being allowed to or recruited into practice early, perhaps even before sitting for NCLEX or even finishing their final exams. An example: A CNO in a large New Jersey medical facility is begging a Nursing Program Director to send her senior nursing students to the clinical site, the NLN is okay with this, but how can she, in good conscience, allow her students to be there without proper PPE? Her students who work as techs at this facility also convey the dire conditions in the facility. Also, her faculty, like most nursing faculty, is older (in this case, age 59 on average) with underlying health conditions, which creates a greater risk for them as well.

My ethical perspective answer to this is that unless adequate supervision and proper PPE can be assured, the students should not be allowed into theses settings, as they will ensure harm to self and others, and we must abide by our ethical responsibility to practice beneficence and nonmaleficence. In my own setting as a director of an RN-BSN nursing program, we decided to remove all of our students from all clinical settings, even though we had students who wanted to stay in these community settings, the risks do not outweigh the benefits.

I also think of the challenges of being a new grad nurse: there is so much to learn and process and in a crisis situation will this even be possible? Will we ultimately end up losing a large number of these new grad nurses to post-traumatic stress and illness? This seems to me to really be lacking an ethic of care toward a very vulnerable population, our new grad nurses.

Is Nursing Political?

I was reminded this week that nursing is of course political. I found an interesting posting about how very political Florence Nightingale was. Cynthia Sim Walter (March 22, 2020, facebook) stated that during the Crimean War, Florence was first known as the Lady with a Hammer; she fought for her nurses to have what they needed to provide proper care, and she beat down military storerooms with a hammer.  I loved this quote: “Military leaders loathed her and feared her. She drank brandy with the soldiers, did statistics for fun, and had no respect for the politics of men,” (I did not fact check this).

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Florence took physical action when nobody else would and her actions were a political act of rebellion to save lives in dire times.

Let’s Reuse Our Masks? Here’s some data 

This is heartbreaking when our leading facilities are looking for ways to somehow sterilize single-use masks. Here is something floating around on social media, put out by Stanford.

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The full report can be read here. It sums up two important things, that autoclave may be effective (the mask will not have the same integrity, particularly over time; please see stats above). Also with the plastic face shields over other masks, we have no efficacy data around their effectiveness (Stanford Report). 

We still need PPE to be well stocked so we can be more assured that we are well protected. We still need to be demanding that.

New Resources and Webinars:

To share more current information, the American Journal of Nursing has joined with Johns Hopkins and others to share ideas around keeping nurses safe. Here’s the link with all the info. https://nurses.wikiwisdomforum.com/

The Schwartz Center for Compassionate Healthcare is offering a webinar on Tuesday, April 7, 1-2 pm EDT, entitled: Leading with Compassion: Supporting Healthcare Workers in Crisis. Register Schwartz Compassion Center Webinar

Be well.

 

 

Nurses’ Concerns COVID 19: Update March 26, 2020


Yesterday, I received an email from Governor Cuomo asking about my availability to be part of the surge, where they are training and employing nurses to be on the front line of care during this pandemic. I am assuming I received it as I am newly licensed in NY state for my job.

Today, I learned from a nurse colleague of this story of an assistant nurse manager dying of COVID19. He had been treating COVID19 patients, was hospitalized March 17, and passed away Tuesday. Kious Jordan Kelly, RN, may he rest in peace, was only 48 years old. It was reported that he had asthma.

Unfortunately, he worked at one of the hospitals, Mount Sinai West Hospital, where nurses were reportedly short on PPE and using trash bags for PPE.

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The nurses were also posting that they were out of masks and they were reusing disposable ones, along with reusing face guards that are simply wiped and reused. Some nurses are stating that the hospital should be held responsible for Nurse Kelly’s death, as they failed to provide him with proper PPE. Despite the pictorial evidence, Mt Sinai denies that the staff doesn’t have proper PPE.

I am seeing a bit of a shift in social media, where nurses are starting to resign or refuse to work due to lack of PPE. Nurses, in general, appear to be more accepting of the idea that some nurses have decided that it’s not worth the personal risk. I think we have to consider that the amount of stress and anxiety this pandemic has caused can also decrease immunity and stress resilience. We need to take care of each other.

Meanwhile, many states are calling for new grad RNs who may not even be licensed yet to be trained and allowed to work in these settings. We all know that ER and ICU type nursing skills that COVID19 patients require are not created overnight: it takes many nurses years of learning and growing toward expertise to be truly effective in these settings. This brings to mind questionable standards of care; as the population in need grows, we will lack the ability to provide skilled care that is needed. Some hospitals are trying to do rapid ICU classes, in literally 2-3 days, attempting to train nurses with some experience to become ICU prepared. I don’t know if that is really effective or possible, and I also don’t have other solutions to offer. I’d love to hear your thoughts on this.

Lastly, I leave you with this great link to the New England Journal where Dr’s Ranney, Griffith, and Jha discuss much of what I have also written about around the Defense Production Act. We need the President to actually enact so ventilators and PPE can be manufactured and distributed here. https://www.nejm.org/doi/full/10.1056/NEJMp2006141

Please, take action: contact your congressional members and the white house and demand that action be taken. https://www.usa.gov/elected-officials

Nurses’ Concerns COVID19: Update March 24, 2020


I heard from a friend of mine who is a nurse; her sister is a nurse who is now off from work because she became very ill with COVID19 after just a few days of working.

I’ve seen nurses in social media posts fashioning PPE from garbage bags and using plain cloth gowns.

I’ve been told nurses are now putting cloth masks over N95 masks (no evidence that this helps and it may actually harm). There is talk on social media of nurses washing or autoclaving or UV sterilizing N95s, although all of these actions likely degrade the masks or render them useless.

The World Health Organization’s guidelines clearly state to not use cloth masks and to not reuse single-use masks. You can download the guidelines here. https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak?fbclid=IwAR2NRGtIs9AIIeI2HWiA5ZnOu4DoQL3GBOr40AvEJxul3Gms8RnQPb_ORCg

Through the social media grapevine, I heard that a health system in California has notified unionized nurses that they can be fired for choosing to wear their own N95s masks in the workplace.  The systems standards of care and use of PPE around COVID19 positive and presumptive positive appears to have degraded due to lack of PPE and CDC claims. I could not verify this, but below is the circulation of the information.

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Lastly, I received notice today that the American Academy of Nursing joined the ANA, AHA, and AMA calling upon the president to enact the Defense Production Act’s authorities in order to ensure that all healthcare providers have PPE and the needed medical equipment to care for people.

You can take similar action; all of the links to contact your legislative representatives and the President are in yesterday’s update posting.

Wishing you wellness and peace.

Nurses’ Concerns COVID19: Update March 23,2020. Take Action.


Today in social media land, nurses state that they are being told to not use PPE for MRSA and VRE and other contact precaution patient care situations. I think we all know the dire implications around this.

Some are claiming that in other countries they have contacted nurses and doctors who do have access to adequate PPE.

Additionally, many are discussing at what point do you refuse to work because you don’t have proper PPE, or any PPE at all. Some nurses are grateful to be working and still have an income, others are worried and exhausted, some haven’t seen their kids or family in a week out of fear of exposing them to COVID19.

There are private companies that are helping hospitals and healthcare systems access more PPE for their needs. A former state legislator from Maine, Diane Russell, has been working as a broker to help state legislators from Massachusetts to procure PPE. So, instead of the federal government helping to ensure that the people on the front lines are protected, states and healthcare systems are having to turn to private organizations for assistance in just finding PPE: https://www.bostonglobe.com/2020/03/21/metro/message-maine-massachusetts-yields-much-needed-medical-supplies/?  I do not know much about the company, I don’t know if the pricing is fair, but I do know they are able to provide many with PPE. https://noblemedicalsupply.com/products

It’s still early on the east coast, but I am not expecting the president to take action on the Defense Production Act today. I implore you to do the grassroots things and contact our representatives.

Be direct and clear; state your name, where you live, your contact information, your profession, and that you are asking them to ensure that the federal government takes action on the Defense Production Act so that healthcare workers have access to Personal Protective Equipment and patients have access to ventilators.

I suggest both phone and email messaging. I suggest leaving messages with the president’s office, and each of your representative federal lawmakers. It took me about 30 minutes to organize myself, write out my message, and both call and email the president, my governor, my federal legislators.

The full list of how to contact all of your federal and state lawmakers is found here on this main landing page: https://www.usa.gov/elected-officials

This link takes you to your house of representatives legislator and provides phone and email contacts: https://www.house.gov/representatives/find-your-representative

This link takes you to the senator’s contact information: https://www.senate.gov/general/contact_information/senators_cfm.cfm

It’s also important to contact your state government and aks them to request that the federal government take action. You can find your state government links here: https://www.congress.gov/state-legislature-websites and also from the main landing page, including your governor’s information.

*Thanks to those of you who dialogued and posted yesterday, though I haven’t had the energy to respond. I am trying to take good care of myself, as I still have a sore throat, headache, runny nose, body aches, no fever. All of the symptom checkers say it’s not COVID19. I wish you all wellness and peace.

Nurses’ Concerns with COVID19: March 20, 2020


Like many of you reading this, I have a range of emotions and feelings as the pandemic of COVID19 grows in the USA: anxiety, fear, and anger. Today (and for the last several days), I am angry about the lack of Personal Protective Equipment (PPE) available for nurses who are being called to care for those who are most ill and the most contagious. The following is my attempt to express my personal concerns and align them with nursing’s guiding ethical principles.

There may be flaws in my thinking and I am open to respectful dialog about these issues. I understand that emotions are running high and that we may not agree, but we can and should have civil discussions and dialogs.

Lack of Personal Protective Equipment. On February 7, 2020, the World Health Organization warned of a shortage of Personal Protective Equipment in China and beyond. As that was 6 weeks ago, there has been time to ramp up the production of PPE. Meanwhile, state’s governors from Maine to Wisconsin to Florida and Washingon are asking to access the federal stockpiles for access to PPE:

https://www.penbaypilot.com/article/governor-mills-urges-federal-government-vice-president-release-personal-protection-eq/131972

https://www.nbc15.com/cw/content/news/Evers-asks-federal-govt-for-much-needed-supplies-from–568975621.html

https://www.propublica.org/article/heres-why-florida-got-all-the-emergency-medical-supplies-it-requested-while-other-states-did-not

https://www.doh.wa.gov/Newsroom/Articles/ID/1117/Addressing-shortages-of-Personal-Protective-Equipment-PPE

Nurses Quitting: A few days ago, one of my Facebook friends quit her job because she was no longer being provided the proper PPE, She was not directly caring for COVID19 patients, but she needs proper PPE to keep herself and her patients safe during the provision of care,  and her quitting her job got me thinking, considering ethical issues, advocacy, the role of the nurse, and so on.  I respect her decision, and I hope this post makes it clear that during these frightening and murky times, the decisions we make as nurses are going to be hard ones.

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I want to say, from an ethical perspective, it is perfectly acceptable for nurses to quit their jobs and/or refuse to work without proper PPE. Refer to my previous post of the ANA calling for the CDC to provide evidence when they make guidelines, and consider the recent use of bandanas and reuse of face masks protocol from the CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html. This flies in the face of everything we know about the transmission of viruses.

Ethical Principles: The overarching ethical principles at play here that help to guide nurses’ decision making are beneficence (doing the good thing, moral obligation to do the right thing, what is best for the patient) and nonmaleficence (do no harm to patients). When we work without proper PPE, there is a very real risk that not only might we harm ourselves, we potentially spread pathogens to patients. When we don’t have proper PPE, our stress, fear, and anxiety can be magnified and potentially may harm patients.

Additionally, The code of ethics for nurses (https://www.nursingworld.org/coe-view-only) requires a lot of us.  To begin with, we must be deeply familiar with The code and how it guides our decision-making processes. The following are some excerpts from The code that guide our decision making at this time:

The code: 3.5 Protection of Patient Health and Safety by Acting on Questionable Practice 

This concept is all about the reporting of inappropriate and questionable practices. We may become stymied when even our boards of nurses are aware of dangerous and non-evidence-based practices, but they may see no way around them. We can report the issues, but when the governing bodies we report to are not holding up our own ethical standards, the field is put at greater risk for collapse (from infection spreading and/ or providers quitting).

Even as standards are relaxed, entities such as the Oregon Board of Nursing should be taking more responsible action and not placing nurses and patients at risk. The following is a statement by the Oregon Board of Nursing that states that nurses cannot refuse assignments because of sub-par PPE that does not align with CDC or WHO regulations. In other words, in this case, the BON is either not considering the greater harm for both patients and nurses by not recognizing the greater ethical concerns and personal risks nurses are being asked to take, or they simply see no other solutions. The paragraphs about the social contract and evidence-based approaches contradict the highlighted area regarding changes in PPE approaches and the right to refuse assignments.

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Regardless of what our boards of nursing state, Provision 4 makes it clear that we are ultimately responsible for our own practice:  “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions, and takes action consistent with the obligation to promote health and to provide optimal care”. Specifically, Provision 4.1 states that “Nurses bear primary responsibility for the nursing care that their patients and clients receive” and “Nurses must always comply with and adhere to state nurse practice acts, regulations, standards of care, and ANA’s Code…”. This does lead to interesting paradoxical issues with the Oregon Board of Nursing, as one could view this as a regulation, but it contradicts further statements in The code, including:

Provision 4.3: “Nurses are always accountable for their judgment, decisions, and actions: however in some circumstances, responsibility may be borne by both the nurse and the institution. Nurses accept or reject specific role demands and assignments based on their education, knowledge, competence, and experience, as well as their assessment of the level of risk for patient safety. Nurses in administration, education, policy, and research also have obligations to the recipients of nursing care” and “Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review”.

Most importantly, The code calls for us to take good care of ourselves so that we can take care of others. We see this shown in Provision 5, particularly:

Provision 5.2 Promotion of Personal Health, Safety, and Well-Being

“…nurses have a duty to take the same care for their own health and safety. Nurses should model the same health maintenance and health promotion that they teach and research, obtain health care when needed, and avoid taking unnecessary risks to health or safety in the course of their professional and personal activities.” The sticking point here is arguing whether or not the risks of not wearing proper PPE, which include risks of death for oneself or other patients who have not yet been exposed, is necessary or not. From my perspective, I can see where working without proper PPE could be too large of a risk to oneself and the communities served.

And I get concerned when nurses seem to think it’s only about them be willing to take on the personal risk for themselves, forgetting about how they may also become the vector.

One last ethical issue, we have to do our own self-care during these challenging times. As nurses, we are required to take care of ourselves. Provision 5.2 continues: “Fatigue and compassion fatigue affect a nurse’s professional performance and personal life. To mitigate these effects, nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs…it is the responsibility of nurses leaders to foster this balance within organizations”

Now onto a round-up of current COVID19 issues for nurses as I am seeing on social media:

Masks: Some nurses are being told to store their 1 daily mask in a paper bag and remove/ doff between patients, and replace/don the old mask for new patients. Of course, the bag and the mask would all be potentially contaminated; the bag actually creates a source of contamination and risks for greater transmission. I also heard rumors on social media of nurses being told to share masks, and I am hoping this is simply just false information, as I couldn’t verify that claim. I did hear that eye shields were being shared. I have confirmed that nurses who are normally required to wear masks because they have not been vaccinated for the flu are now being told to not wear masks because there is a shortage of masks. I have also confirmed that having a doctor’s note regarding why one must wear a mask (verification that they are immunocompromised) may work in some settings to either ensure masks are available to the person or excuse them from work.

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We are vulnerable: Nurses are humans and many of us are vulnerable, whether that means we have chronic health conditions and co-morbidities, or we are at risk because of age.

Nurses are also fighting amongst themselves about whether it is okay to quit the workplace now. We have to recognize that these are complex decisions; nurses are real people who have their own health issues. Getting angry about people not willing to take the risk is not productive in both the short and long term.

It’s okay to choose your life and your well-being over the “duty” or social contract to work. It’s okay to make those tough decisions, like quitting your job, and, for some folks, they may be willing to risk their license by refusing assignments where they can’t keep themselves or their patients safe, even if their board of nursing disagrees.

Many nurses will carry on, work hard, provide excellent care, and do their best.

It’s also okay to feel vulnerable and scared in these uncertain times and to question your decisions and the decisions of administrators, regulators, and leaders.

It’s okay to organize and advocate for our needs, whatever that looks like.

Always remember, you have ethics on your side.

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