Nurses’ Letter of Declaration Against the Russian War in Ukraine


Contributors: Marsha Fowler,
Deborah Kenny & Elizabeth Peter

Introduction

Soon after Russia invaded Ukraine, it became apparent that immediate action is needed, as innocent lives continue to be lost. We nurses are in a perfect position to do so. Nurses have a large, trusted, and strong voice to advocate for the Ukrainian people and issue a call to action for legislators to put an end to these amoral acts. Sometimes during war, civilian collateral damage is unfortunate and inevitable, but Russia’s targeting of healthcare facilities, churches, schools, and other non-military objectives clearly represents war crimes. To assist all nurses in this advocacy, Dr. Marsha Fowler (US) crafted the attached letter with further input from Dr. Deborah Kenny (US).

Please download and distribute widely the attached letter via your professional social networks and organizational channels. Send to your state Congressional representatives or other leaders representing your individual country. Please tailor for your own country as necessary. Distribute it to nursing students to show them how to advocate through policy action. Together nurses can have a tangible and significant impact on the global health and wellbeing of all individuals. Nurses can be a compelling force for good in the world. Call upon your respective nations governments to take swift and decisive action to end these war crimes against humanity.

US nurses: We encourage each nurse to contact your own Congressional legislators (or legislative body members) and the White House. Congressional members can be found through https://www.congress.gov/members.  Additionally, nurses can flood the White House switchboard at (202) 456-1414. It is staffed by live volunteers who tally calls. Call the White House to express your concern and you may use the letter as a template.

Download Letter in PDF format
Download Letter in Word format

Letter

Attn: President Biden, Vice President Harris, Sec. Blinken, Speaker Pelosi, Majority Leader Schumer, Congress, Chairman Milley, Secretary–General Guterres, President von der Leyen, President Roberta Metsola, Director–General Ghebreyesus:

We write to express our profound concern regarding the unjustified, unprovoked, and illegal invasion of Ukraine. Those who sign below represent nurse-leaders, many specializing in bioethics and, as such, we hold dear human life, health, well-being, human solidarity, dignity, freedom, and social justice as core values of our profession. These core values of the nursing profession, affirmed by the fields of bioethics, ethics, and social ethics, are themselves desecrated in Russia’s military invasion of Ukraine. Our concerns and requests are several:

We call upon the United States and the UN and its member nations to hold President Vladimir V. Putin of Russia accountable for multiple and egregious violations of the Hague Regulations of 1907, the Geneva Conventions of 1949 and its associated Additional Protocols, and the Rome Statute of the International Criminal Court.

Under Mr. Putin’s command, the Russian military have committed numerous violations of these regulations, conventions, protocols, and statutes. In particular, we draw your attention to violations of Geneva Conventions that specifically require:

  • respect for “hospital and safety zones and localities so organized as to protect from the effects of war, wounded, sick and aged persons, children under fifteen, expectant mothers and mothers of children under seven.”
  • respect for neutralized zones
  • protection of civilian hospitals
  • that “Persons regularly and solely engaged in the operation and administration of civilian hospitals, including the personnel engaged in the search for, removal and transporting of and caring for wounded and sick civilians, the infirm and maternity cases, shall be respected and protected.
  • that “Convoys of vehicles or hospital trains on land or specially provided vessels on sea, conveying wounded and sick civilians, the infirm and maternity cases, shall be respected and protected in the same manner as the hospitals provided for…”

Moreover, we express our outrage at the multiple violations of virtually every regulation under Article 51 of the Additional Protocol of the Geneva Conventions on the Protection of the Civilian Population. These have been made visible to the public through multinational war correspondents. The Hague and Geneva Law identify many of these violations as war crimes, e.g., the illegal use of thermobaric blast weapons against civilians and civilian sites.

We call upon the United States and the UN and its member nations to investigate, document, retain evidence, and try Mr. Putin for the commission of war crimes, genocide, crimes of aggression, and crimes against humanity, consistent with the evidence that is obtained, including but not limited to:

  • Intentionally directing attacks against the civilian population as such or against individual civilians not taking direct part in hostilities;
  • Intentionally directing attacks against civilian objects, that is, objects which are not military objectives;
  • Intentionally launching an attack in the knowledge that such attack will cause incidental loss of life or injury to civilians or damage to civilian objects or widespread, long-term and severe damage to the natural environment which would be clearly excessive in relation to the concrete and direct overall military advantage anticipated;
  • Attacking or bombarding, by whatever means, towns, villages, dwellings or buildings which are undefended and which are not military objectives;
  • Making improper use of a flag of truce, of the flag or of the military insignia and uniform of the enemy
  • Intentionally directing attacks against buildings dedicated to religion, education, art, science or charitable purposes, historic monuments, hospitals and places where the sick and wounded are collected, provided they are not military objectives;
  • Pillaging a town or place, even when taken by assault;
  • Employing weapons, projectiles and material and methods of warfare which are of a nature to cause superfluous injury or unnecessary suffering or which are inherently indiscriminate in violation of the international law of armed conflict. (From: Article 8 of the Rome Statute of the International Criminal Court)

While sanctions do not stop material aggression, harm, and damage to life, infrastructure, and environment, we call upon the United States and the UN and its member nations to place, consistently tighten, and maintain sanctions against Mr. Putin and his government so that he is economically and forcibly constrained in his action.

Mr. Putin has waged an unprovoked and unjustified war on a sovereign, democratic nation and has indicated his intent to carry through to the end his invasion until he achieves the full surrender, submission, and subjugation of the Ukrainian people. He has thus indicated that he will not negotiate withdrawal, rendering diplomatic solutions null. He has also indicated that sanctions will not affect his plans for Ukraine. Past statements have indicated his general contempt for Ukrainians and that Ukraine has no right to exist as a country. His invasion and wanton killing in Ukraine are genocidal. And, there is no indication that he will stop with Ukraine, following as it does his military actions in Syria, Chechnya, Georgia, Crimea—including the razing of Grozny.

We call upon the United States and the UN and its member nations, to intervene with increased humanitarian aid both, for the Ukrainian nation and its refugees, and to increase aid to refugee-receiving nations and conflict adjacent nations.

In addition to increased governmental aid, we ask that a central website be established for Americans (and in other nations) with links to authenticated governmental or non-governmental organizations, where donations can be specified for and directed toward aid to Ukrainians and/or Ukraine resistance and Ukrainian refugees.

We call upon the United States and the UN and its member nations, to markedly increase aid to the Ukrainian citizenry to increase their capacity for resistance to Russian invasion.

We support increasing the supply of rations/food, protective gear, field first aid and medical supplies, communications equipment, and those supplies necessary to support the resistance of the Ukrainian people. In addition, we also support the provision of arms, weapons, munitions, armored vehicles, armored fighting vehicles, planes, surveillance equipment, drones, classified surveillance information, cybersecurity expertise, and more.

We call upon the United States and the UN and its member nations, to provide for the medical and nursing needs of the Ukrainian populace, and nurses (and physicians) giving care under wartime conditions.

This war follows upon the heels of the Covid pandemic which had already strained medical and nursing resources in Ukraine. We ask our nation and the UN and its member nations to increase its provision of medical and nursing resources including but not limited to clothing, birthing kits, hygiene kits; cleaning, disinfecting, and sterilizing supplies and equipment; medical and surgical supplies and instruments; head lamps; tourniquets, bandages, and wound care kits; nutrition support for infants, children, and adults; blankets, towels, diapers, isolettes, bassinets, medications, antibiotics, and infusions; disposable scrubs; ambulances, and stretchers. In addition, nurses and physicians are living in hospitals in Ukraine and need personal support with food, warm clothing, ground cold-barrier foam for sleeping, blankets, clothing, and personal care items.

We call upon the United States and the UN and its member nations, to provide the necessities and comforts for the particularly vulnerable in Ukrainian society.

Many of the women, children and elderly persons have had to take cover in underground stations, basements, subway tunnels, and bunkers. We ask that our nation coordinate with NGOs and the International Red Cross to increase the donation of such things as clothing, shoes/boots and socks, blankets, ground-insulating foam rolls, food; child education and amusement kits and comfort toys; hygiene kits; feminine hygiene supplies, reading materials, communications tools; candles and flashlights and batteries, head lamps; supportive religious items; warm clothing, and other necessities.

We call upon the United States and the UN and its member nations to create collaborative and coordinated structures that can support the work of volunteer nurses and midwives who enter conflict zones to ameliorate the excess demands that fall upon the nursing and midwifery work of nationals in conflict zones.

The world is never free of war. War places even greater demands upon both military and civilian nurses and midwives. We call for the creation of an international structure and system of coordination and support for nurse and midwife volunteers who are willing to serve in conflict zones. The remarkable Médecins Sans Frontières, is a model that could be extended to an international cooperative and collaborative system of organizations and agencies, that are materially supplied by their nations of origin or international donations.

We are, collectively, horrified both at the invasion and the conduct of this war. As Mr. Putin appears to accept no diplomatic solution other than utter surrender and accession of the Ukrainian nation and its people into Russia, we ask our nation, and the UN and its member states, to do all in their power to force an end to this war, to maintain the sovereignty of the Ukrainian nation and its populace, to aid the Ukrainian resistance, to bring aid to the people of Ukraine and its refugees, to aid refugee–receiving nations, and to harden other nations against Russian expansionism, invasion and cyberattack.

In affirmation of the dignity of human life; the value of health, well-being, respect, and freedom; the hallowed nature of the natural environment, and our commitment to justice and peace as nurses and bioethicists, we humbly submit these requests and urge stringent intervention to halt this unjustified war, to punish war crimes, and to restore Ukraine and the Ukrainian people to sovereign status.

Sincerely,

The Invisible Brown Immigrant


Contributor: Binita Thapa*

Binita Thapa

This poem has been inspired by my experiences of racism and discrimination in healthcare and nursing education. In the first part of this poem, I portray my experiences of discrimination in healthcare starting from the ambulance’s refusal to take me to the hospital to nurses under recognition of my pain, all due to ongoing appendicitis. I later illustrate an experience of racial discrimination in the form of exclusion as a Masters student in my school. These experiences were pivotal in not only making me realize the racialized world that I was a part of yet I did not acknowledge and recognize for a very long time but was significant in radically changing the trajectory of my thesis from end-of-life care to racism in nursing. These racialized experiences undoubtedly lowered my confidence and belonging, further oppressing me at times but was also a final thread to my unbearable urge to fight for social justice in nursing. I have now healed myself from these racial injuries with the validation, support, and mentorship from many allies and minority nurses. I am also proudly liberated from oppression. However, nursing education and healthcare continue to become a hostile place for racialized nurses and this poetry piece is a starting point of my reflective activism in fighting systemic racial injustices in nursing.

I open my eyes, I see my partner scream at me begging me to wake up
I see myself lying on the kitchen floor
Cannot recall where I was before
His eyes so desperate, his voice shaken, and his soul fragile
Never had I seen him so agile
Ambulance arrives with such an ease
So were the paramedic attendees
He tells me that I cannot be served sounding reserved
My unbearable pain did not matter, not enough to receive attention
I question myself, why am I an exemption?
His disengaged eyes and white skin
Nice racism as it is, nothing less than a brutal sin
Would my pain ever matter?
Will my pain ever be enough?
I could see my shadow and my feet yet I am unnoticeable
I am just a brown immigrant and my superpower is to be invisible

I stand there in front of my nurse in the hospital three feet away
Hoping that he would look at me without delay
He is sharing jokes with his colleagues
As if that is one of his side gigs
I question to myself: why aren’t his jokes funny to me?
Or is it my pain that is more bothersome to me
I bend down to put my hands on my knees
That is all I have to support my unease
I talk to myself inside my head ‘don’t fall’
‘Please can someone give me a medication to relieve this downfall’
I am clearly visible yet unseeable
Proof are these blank stares of disapproval
I could see my shadow and my feet yet I am unnoticeable
I am just a brown immigrant and my superpower is to be invisible

I sit there in a chair in front of my nursing professor
Her evil smirk, I still clearly remember
She proceeds to tell me that I do not belong here in nursing
Her words come out in such ease
As if dehumanizing racialized students was her expertise
All I hear in my soul is how dare that I am ambitious
Making my white professor have this urge to be this malicious
I walk outside her office, trying to make sense of the event that made me so nauseous
I could feel the warmth of my face increasing
As if my body and mind is exploding
The feeling of being unwanted and unwelcomed is suffocating
The proud nurse that I am but this feels humiliating
I could see my shadow and my feet yet I am unnoticeable
I am just a brown immigrant and my superpower is to be invisible

I question to myself ‘why me’?
Why don’t I have the courage to say ‘try me’?
A realization that racism and discrimination will be never-ending
A choice at hand either oppression or liberation
Oppression appears familiar, expected, and feasible
Liberation seems disobedient, challenging, and impossible
I desire love and humanity
I choose liberation and nonconformity
I refuse to be dehumanized by thousand cuts
I refuse to be silenced, asserts my blood and guts
The invisible brown immigrant is now awake
Unwilling to go back to sleep
She fights, persists, and continues to exist
Unaccepting to be dismissed
She now sees her shadow and her feet, and fights to be noticeable
She is now an empowered brown immigrant regardless of white disapproval
And, her superpower is her non-negotiable demand to be visible

About Binita Thapa

My name is Binita Thapa, an immigrant, a daughter of immigrant parents, an internationally educated nurse, and the first university graduate in my family. I completed my Practical Nursing degree from Centennial College followed by BScN from Ryerson University. I am currently a PhD in nursing student at the University of Ottawa. I am deeply passionate about social justice in nursing. As a woman of colour in nursing education and someone who endlessly faces systemic marginalization and racialization in my nursing school, my goal is to continue to have a voice for myself and for other racialized students. My doctoral thesis is focused on developing a post-colonial and anti-racist foundation for graduate nursing curriculum at the University of Ottawa.

#DetentionIsDeadly  #FreeThemAll #D4CCQuiltProject


Guest contributor: Jane Hopkins Walsh

Background

 Social justice movements have historically incorporated arts based visual components to amplify their messages by using images and visual art to literally making the invisible more visible. Examples of this include Judy Chicago’s Dinner Party  and the AIDS quilt

As an arts based medium, quilts are powerful semiotic vehicles for protest and memory, and actual representations of comfort and care. Throughout history, suffragettes, abolitionists, enslaved people, Vietnam war protesters, and HIV/AIDS and 911 survivors have used fiber art and the quilt medium to come together in communal spaces for the purpose of grieving, memorializing and honoring others, and for communicating political opinions about important issues of the day.

This week, health care providers from the group called Doctors for Camp Closure, (D4CC) are coordinating a nationwide 24-hour protest vigils outside detention centers to draw attention to the serious risks of infection from CoVid-19 in detention centers and prisons nationwide. In solidarity and collaboration with community groups around the nation, D4CC are incorporating many arts based events including poetry reading, music, story telling, reflective journaling, and the creation of a virtual and actual protest quilt called the #D4CCQuiltProject.

 Using the social media platform Instagram and the use of the project hashtags, the virtual  #D4CCQuiltProject project will “sew” together images from the nationwide protest, banner messages, and other images or words drawing attention to the risks of CoVId-19 infection for detained and incarcerated people. The #D4CCQuiltProject can also spotlight less obvious historical and structural issues of the Capitalocene that are driving refugees to immigrate around the globe including persistent white settler colonialism, neoliberalism, militarization, persistent extraction of living and non living resources around the world by the Global North, and climate related extremes- all factors driving im/migration globally and to the US, and contributing to conditions of extreme poverty, violence, and food and water insecurity throughout the world. Structural violence issues 

MIssion Statement:  The #DetentionIsDeadly  #FreeThemAll Quilt Project messages are intersectional social justice messages and may include these ideas among others :

  • Show healthcare worker support for the Free Them All movement to release people detained by ICE during COVID pandemic, draw media attention to the dangers of incarceration, and increase public support for decarceration
  • Prisons and detention centers are filled with impoverished Black and Indigenous People of Color, and Undocumented People, and they are increasingly the largest sites of COVID-19 infection
  • Social distancing in detention or prison to reduce the risk of COVID-19 is impossible.
  • As health care providers we oppose detention.
  • Many prisons and detention centers in the US are capitalist oppressive for-profit systems that filled with people who have been disadvantaged across generations by the very systems that now hold them prisoner.
  • Migration to the US is driven by intersectional issues for which we as US citizens are complicit including US colonialism, climate injustice, capitalist extractive industries, globalization and neoliberalism (think sugar, palm oil, hydroelectric power, coffee, lumber, beef, global agriculture to name a few).
  • Native American and Indigenous land rights issues in the US are erased within discussions of immigration. (One example among others is: May 2020 The Wampanoag Tribe in in Massachusetts are struggling to retain land rights).
  • LQBTQI issues get erased in the discussion of immigration and detention.

Project Vision   

  • A virtual quilt that “sews” together square virtual images that align with the purpose of the action. and/or 
  •  An actual quilt that has names, images etc on fabric and that can be actually sewn together and/or 
  • An intersectional art project that is open to the greater art community. 

Project Guide: How to Participate 

DIRECTIONS  

There are TWO WAYS TO PARTICIPATE IN THE QUILT PROJECT

VIrtual Quilt 

  • Take a square photo of any message or image that aligns with issues of social justice, examples above, open to interpretation; the only restriction is the photo/image must pass minimum standards for social media, ie) non vulgar non obscene etc
  • Can be poetry, single words or phrases, a photo of a flower, headline in news, anything, names of deceased persons to honor who have been impacted by structural violence, See some image examples below. 
  • You may superimpose a message on a photo you already have. You may superimpose the project hashtags, or a message on a picture of your Protest Banner.
  • A Square image is needed to “fit them together “
  • Upload to Instagram with 3 primary hashtags #DetentionIsDeadly  #FreeThemAll#D4CCQuiltProject
  • Secondary hashtags are fine too but you have to use these 3 so we can “find” the “images” on Instagram you can also Tag @doctorsforcampclosure 
  • Ultimately, the images can be placed on colored squares see below and “sewn” virtually into a virtual quilt. This will happen in the near future after we have a number of images.
  • The quilt will be shared on social media to amplify the messages

Actual Quilt

  • During the vigil, before or up to two- four weeks after vigil,  people can mail me 12 by 12 inch squares of actual fabric with messages hand written or sewn , and I will sew them together and make them onto a physical quilt. 
  • Any fabric is acceptable but dimensions should be 12 inches by 12 inches
  • This is a way to get the public, friends, kids,  and family members involved in this cause.
  • People can include the creation of a physical square as a way of reflecting during the 24 hour vigil. Think child art, spontaneous, no pressure to have any “art” or sewing skills. Just has to be about 12 by 12 fabric based no rules on type of fabric.
  • People can invite local community groups to participate in the creation of squares.
  • PM Jane Hopkins Walsh for address where to send fabric.
  •  Fabric must reach me by +- June 15th 2020. 
  • The actual quilt could be part of a larger traveling protest quilt that gets added on to in other future protests. 
  • Ultimately the actual and the virtual quilt could be part of larger intersections with the art community to amplify and intersect our messages. For example we could have sew-ins in protest in NYC or other places, intersecting with other protests, or the quilt could travel to other cities and immigrant groups to include diverse social movements and groups all over. This is fluid and open to discussion as it unfolds.

EXAMPLES OF IMAGES BELOW- PLEASE IF YOU SHARE THESE IMAGES  GIVE CREDIT  AS LISTED BELOW.

Credit these 4 tags for this image above please
@voxpopuliprintcollective @shimartnetwork #voxpopuliprintcollective
#shimartnetwork

Credit for this image: from Twitter user@denimfemme Lou Murrey

Credit for the quilt images are
Instagram @janewalsh357 #BorderQuiltProject

Credit for the two quilt images above are
Instagram @janewalsh357 #BorderQuiltProject

Credit for this image
@voxpopuliprintcollective @shimartnetwork #voxpopuliprintcollective
#shimartnetwork

 

About Jane Hopkins Walsh

Protest Opinions in this document are My own
Pronouns She / Her
Jane Hopkins Walsh MSN, PNPC
Pediatric Nurse Practitioner
Primary Care at Longwood
Boston Children’s Hospital
300 Longwood Ave
Boston, MA  02466
jane.hopkins-walsh@childrens.harvard.edu

Volunteer and Board Member
Cape CARES
Central American Relief Efforts
www.capecares.org

PhD Candidate and Research Fellow
Boston College
William F. Connell School of Nursing
Enrolled: Center for Human Rights and International Justice
Lynch School of Education
Jonas-Blaustein Scholar Cohort 2018-2020
walshjm@bc.edu

 

 

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.

Screen Shot 2020-03-20 at 8.55.47 AM.png

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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Evaluating the Evidence: Cannabis and Psychosis, Part II


As promised, I am back with more of the analysis. Before I jump into the findings, I do want to let you know I have been ruminating a bit about the issue of cannabis testing. 

To attempt to state my thoughts succinctly here, until we start testing the cannabis that patients in these types of studies are using, we won’t be doing good science. Granted, we know that THC is responsible for many of the side and and adverse effects of cannabis, but to state that the issue with the cannabis is that it has become so high in THC% is far too reductionistic. There is no specific proof that this one cannabinoid alone is the issue when it comes to the relationship between cannabis and new onset of psychosis. The researchers did state that they opted not to test patients’ cannabis because it provides only a snapshot of a moment of cannabis use in the person’s history.

However, relying on reports of what cannabis is available in the area, because it still in my mind, when I think of the wide variety of cannabis strains available, leaves too much of a gap in getting a handle on what patients are actually consuming. Cannabis is a complex plant with over 500 chemicals, but a few simple tests could provide a wealth of information when it comes to determining if high potency THC cannabis truly does play a role in onset of psychosis, or if something else is going on here.

If a similar study were run again, I would suggest testing the actual cannabis that these psychosis patients had used. Those tests should minimally include the cannabinoid and terpene profiles, in addition to testing for heavy metals and pesticides. While this would have some associated costs, it may at least let the researchers know if the profile of the last cannabis used, which could be very enlightening.

Another consideration with testing cannabis: there is a long history of concern when it comes to the role of heavy metal ingestion and the onset of psychiatric symptoms (Attademo , Bernardini , Garinella , & Compton 2017; .Orisakwe, 2014 ). Cannabis plants can easily become contaminated with heavy metals when grown in soils containing heavy metals. Pesticides can also contaminate cannabis, and the consideration of pesticides as both endocrine disruptors and a possible contributing factor to schizophrenia/.psychosis has also been researched over the years (Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, , 2016). What if what we really need to regulate or worry about is not the cannabis plant and THC potency so much as what contaminants are in the plant? In my thought process, this really becomes an ethical question of what we are researching, and what might actually bring harm to patients and vulnerable populations. One of the issues around the end of cannabis prohibition and the beginning of regulation of cannabis should be that people have access to a an herbal medicine that is tested and safe, so people know what they are consuming. Beneficence and autonomy come to mind.

This would encourage cleaner product to be produced and help support people with their own healing quests and/or help them to be a more informed consumer. While I don’t particularly care to draw analogies to alcohol (which comes with its own costly public health concerns namely that alcohol is potentially deadly and cannabis is not), imagine buying alcohol without knowing how strong it is, what is really in it, and so forth. Remember the days of prohibition of alcohol and all of the issues with people making “moonshine”?

And now I will continue to look at the findings. 

Participants: Theres seems to be a good split between male/female, with the median age of 36 for control and 31 for case. The median age coupled with the wide range of ages (18-64) included in the study was just a bit concerning, because we know that first time psychosis tends to happen in the early-mid 20’s. The vast majority of all participants were white with at least some college or vocational training and full time employment. It was also clear between case and control, there was much more use of cigarettes, cannabis, and other “drugs” (stimulants, hallucinogens, ketamine, etc) by the case group. Alcohol was not included the summary data table, but in the body of text it states there no difference in alcohol consumption amongst the case vs control groups. And this points to another issue, that it’s really hard to control these types of studies, because most people who are using “drugs” tend to use many different types of substances and it is hard to determine which is having the impact, particularly as we know their can be short term and long term implications. I began to question the issue of poly substance abuse perhaps being a greater issue here then just looking at the % of THC in cannabis, and that lead me to this research….

The International Early Psychosis Association published research by Neilsen et al (2016) that found that alcohol, cannabis, and other drugs increase risk for developing schizophrenia later in life. This was a large retrospective study with the Danish population. The full paper can be accessed here: https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf Actually, as I ruminate and dig deeper into the Neilsen et al study, I discover it’s having the diagnosis of substance abuse that is correlated with the risk for being diagnosed with schizophrenia 6 fold.  Indeed both cannabis and alcohol greatly increased the risk for diagnosis, but Neilsen et al are careful to state that they cannot say alcohol and substance abuse caused the schizophrenia.

Let’s keep in mind with the study being analyzed DiForti et al (hopefully you aren’t getting lost as I move between the primary study and supporting studies I have included!) also found in their population that most people who have a substance abuse disorder do not use one substance alone. In fact the case participants in most of the drug categories used nearly twice as much as the control groups. So is poly substance abuse a factor here? 

And that brings me to my next thought: Self-medicating. I don’t see this addressed at all in this article, but were the participants asked about why they used cannabis? Seeing as most people with  psychosis have at least 1 year of symptoms prior to being diagnosed with the new onset psychosis, during that time they may be self-medicating or abusing many different substances. My mind starts to question: What if cannabis is actually helping them manage their symptoms, and they would actually would be worse off without it?

And then I come along this little article, that although it’s not in a peer reviewed journal, it clearly explains a possible link between THC, reduction in glutamate, lowered NMDA, weakened CB1 receptors, dopamine receptor D2 being elevated….all this comes together to create hypersensitivity in the limbic system, which may create an environment where schizophrenia could occur.  I didn’t see any of this info in the article be analyzed, f I missed it, somebody let me know! There is conflicting research on whether CBD might help with schizophrenia as it changes/modulates CB1 receptors, but we can ‘t forget that CBD % is an important consideration when looking at cannabis plant profiles. https://www.leafly.com/news/health/link-between-cannabis-and-schizophrenia

The leafy article also linked me out to another article looking at causation between cannabis use and psychosis. The authors Louise Arseneault (a1), Mary Cannon (a2), John Witton (a3) and Robin M. Murray

in their meta analysis of five other research articles found that while youthful cannabis use may create a two fold  a risk factor for psychosis, and may be responsible for up to 8% of the worlds schizophrenia diagnoses, it also is just one part of a “complex constellation of factors”, and of course vulnerable youth should avoid use of cannabis. 

What if people with mental health issues find some relief, for some period of time, from cannabis, that they don’t find from other medications or activities? Why are there so few qualitative studies around cannabis use and self-medication? And why do we have such a stigma associated with self-medication, in much the same we have a stigma around being diagnosed with a mental health issue? The questions go on and on in my mind. 

Overall Findings: Okay, let’s get down to the meat of the findings here. The statistical analysis seem logical and well run (I am not a statistician, in fact I found a statistician to work with as I am doing my own quantitive study on an unrelated topic at this time.).  

Simply stated, the findings correlate starting use of cannabis before age 15, using high potency cannabis (>10% THC), and  daily use as seeming to have the greatest correlation to psychosis (keep in mind causation is not proven here, and almost all of the case participants had also indulged in other substance use at much higher rates than the control group, the issue of possible contamination of ingested cannabis, the lack of knowledge around the full cannabinoid and terpene profile of the cannabis used, and so on). 

Conclusions: For me personally, this study did little to change my mind about cannabis and its safety profile, nor change my overall thoughts on safe use of cannabis, including the idea that cannabis should likely not be used recreationally by young people in their teens and early 20’s.

For most people using cannabis medicinally,  a high potency THC cannabis is likely not needed, but having safe tested cannabis helps people to make informed decisions about the quality of cannabis they are ingesting and the amount of THC they are consuming. High potency THC cannabis or escalating doses of THC may indeed be risky for some people, most likely young people, those with a predisposition to addiction or history of familial psychosis episodes, those with childhood trauma, those with familial history of substance abuse, and those who currently are poly- substance users. 

  • Avoid using cannabis (and really all “drugs” and alcohol) until one is in the mid-20’s and the brain is well developed. This does not account for the idea that teens will use substances, so I would say avoid poly-substance use, and cannabis is still generally safer than alcohol (psychosis risks aside). Alcohol is far more readily available for teens to access, also it too is a significant risk factor for psychosis (and of course immediate death if one becomes extremely intoxicated….you can’t die from cannabis ingestion).
  • Use tested cannabis that is free from heavy metals, pesticides, fungus, and mold.
  • Know the potency of the cannabis medicine you are using. Avoid long term use of “high potency THC cannabis”, or better yet know your THC consumption in mg and limit it to 15 mg max/ day (divided into TID doses), balanced with CBD (up to 20 mg/ day) and terpenes from whole plant medicine (MacCallum & Russo, 2018). 
  • Take regular cannabis breaks (for the recreational user,  avoid daily use and avoid regular use of high potency THC strains; for the medicinal user, consider working with your healthcare provider to determine what a break schedule might look for you, and use lower THC strains if they are still effective at managing symptoms). The website www.healer.com has great info about dosing. 
  • Medicinal users of cannabis: start low, go slow with the THC dosing. One does not need to be “high” in order to feel relief of symptoms, and with cannabis being a biphasic medication, sometimes less is more. For specific dosing guidance, see MacCallum & Russo (2018). 
  • For researchers: as prohibition ends and we move toward an era of regulation, let’s find ways to create the best body of evidence available when it comes to the benefits and risks associated with this herbal medication. Let’s base our public policy and educational efforts in sound science. Let’s not jump from correlation to causation, which means we will have to approach the study of this plant with a complexity lens. 

 

References:

 Arseneault, L.  (a1), Cannon, M.,  (a2), Witton, J.  (a3) & Murray, R.M. (a4 .

(2004). Causal association between cannabis and psychosis: Examination of the evidence. The British Journal of Psychiatry, 184(2), 110-117. https://doi.org/10.1192/bjp.184.2.110

Attademo L1, Bernardini F2, Garinella R3, & Compton MT4.(2017). Environmental pollution and risk of psychotic disorders. Schizophrenia Research, 18, 55-59.

MacCallum, C.A.. & Russo, E.B. (2018). Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 49 , 12–19.

(Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, ,(2016). Review of endocrine disorders associated with environmental toxicants and possible involved mechanisms. Life Sciences, 145, 265-273. 

Nielsen, S.M., Toftdahl, N.G., Nordentoft, M., & Hjorthoj, C. (2016). Association between alcohol, cannabis, and other illicit substance abuse and the risk of developing schizophrenia: A nationwide population based register study. Retrieved from https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf

Orisakwe O. E. (2014). The role of lead and cadmium in psychiatry. North American journal of medical sciences, 6(8), 370-6.