Leadership

Nurses’ Concerns COVID19: Update March 29, 2020

/ Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN

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 with COVID19: March 20, 2020

/ Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 7 Comments

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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A tribute to Virginia (Ginny) Ward Paulsen (1918-August 9, 1982)

/ Peggy L Chinn / 4 Comments

Contributed by Rorry Zahourek

Ginny Paulsen was not a nurse by profession but by heart and dedication. She served as the Executive Director of the Colorado Nurses Association from 1961-1980. In that role she inspired many to become activists on numerous fronts (clinical and political). At that time in Colorado the nurse practitioner was born and clinical specialists programs were producing new and motivated practitioners. She supported a group of nurses at Denver General Hospital to organize and demand a job description and commensurate salary for Clinical Nurse Specialists. In the 1970’s Ginny supported a group of nurses to go into private practice by providing moral support, business advice and legal consultation. Later she helped the group writing a book that described the process of setting up one of the first primary nurse clinics in the country.

She was a realistic idealist. She believed in the goodness of humanity and that we as nurses and humans could forge new roles, advance the profession, health care and change the system as a whole.

She always had good advice regarding negotiating systems and was always available for consultation when we met obstacles. She was a fierce and intelligent nurse advocate who mentored many in expanding their scope of practice and securing the legislation needed to support those advances.  She developed and hired one of the first nurse lobbyist at the State capitol in the country. (See picture of Ginny with with the first nurse lobbyist, Sue Sawyer).

Ginny also started a major international educational conference (Chautauqua) to promote discussion of issues and foster activism. This conference continues today. She birthed the idea of having risk taking workshops. These fostered activism for expanding nurses’ roles, practice and changing systems. The result of one of those workshops was the formation of Nurses for Political Action Colorado. This group provided forums for candidates to present their views and discuss issues related to overall health care and nursing.

Her premature death was and is a loss. I’m sure she would be supporting this nurse activist group and would be pleased to see how many members it has that are committed to making changes for nursing and for all to have adequate health care.

Ginny on the left with Sue Sawyer (right)

Breaking: Report of new study on nurses and the media!

/ Peggy L Chinn / 3 Comments

The original Woodhull Study raised awareness that the voices and perspectives of nurses, the nation’s largest group of health professionals, were largely invisible. Twenty years later, researchers revisited that landmark study on May 8, 2018, to determine whether nurses’ representation has improved or remained static.  Sadly the outcome shows the situation is worse – but also revealed keys to changing this going forward.  For more information, go here.  Watch for our “Inspiration for Activism” feature coming tomorrow of Diana Mason, leader of the study team!

To Men in Nursing: Consider Your Privilege

/ jillianprimiano / 44 Comments

I want to talk about men in nursing and privilege. I expect it will be a difficult, nuanced dialogue, but it’s an important one, and one particularly relevant to nursing, a profession so entwined with the ideals of egalitarianism, advocacy and feminism.

Before I begin, I want to clarify: I do not want to challenge the presence of men in our profession, their growth in numbers, their competency, or their intentions. I do want to challenge men in our profession to challenge themselves to analyze their privilege, and I want to challenge men in our profession who have already done this work to challenge others to do the same. Specifically, I want to challenge male nursing groups, particularly NYC Men in Nursing and the American Association of Men in Nursing, that provide networking and career opportunities for their mostly male members. Broadly, I want to challenge all male nurses who use their privilege, inadvertently or purposefully, to get higher positions and higher pay.

I identify as an intersectional feminist. Intersectionality is a term used by modern feminists to define the multiple identities that are subject to systems of oppression. An intersectional feminist holds that arguing against sexism is logically and ethically invalid if you do not also rally against racism, classism, homophobia, transphobia, queerphobia, ableism, ageism and religious discrimination in our society. Intersectional feminists work hard to examine their own identities of privilege (I, for example, am white, able-bodied, cisgendered and educated) and how they have benefitted us, and work to dismantle the systems that bolster that privilege. Intersectional feminists “call people in” instead of calling them out.

I often discuss experiences of discrimination in the workplace with other non-male identifying feminists, and through these conversations, I learned I am very lucky to be a nurse. Compared to tech or the restaurant service industry, for example, nursing is a feminist dreamland. Most men I have met in nursing have been respectful and compassionate. Disappointingly, however, only a few have demonstrated a deep understanding of the privilege they enjoy, both in our profession and society at large, due to their gender. Male nurses have great capacity to be intersectional feminists, but because they do not bear the brunt of gender inequality, it takes more work for them to recognize it than it does for women, and because it’s hard to say no to a leg up, it takes more self-sacrifice to shun its benefits.

As an intersectional feminist, I empathize with the position of men as a minority in an industry. They comprise only about 10% of nurses. Male nurses have historically been made fun of for being feminine (I’ve seen the movie Meet the Parents), which I’m sure can be hard for some men. Male-identifying nurses who are gay or queer suffer homophobia in the workplace. Our black male nurses come from identities that have higher rates of imprisonment, police brutality and death by homicide. Men are also more likely to be mistaken for doctors, according to one male classmate of mine, for whom I played my well-worn miniature violin. Seriously, though, I empathize with all of this and readily acknowledge that some identities men have (race, disability, sexuality) put them at higher risk for discrimination than some women. I even empathize with the doctor comment, but mostly just because I am proud to be a nurse. 

But we must remember, a minority population is not always a victimized one. Male nurses are more likely to hold advanced practice positions, and they earn more money than female nurses in comparable positions with comparable accreditation and experience. Men are less likely to be the recipient of sexual harassment from a patient or coworker. Men are less likely to be demeaned and ignored as professionals by MDs and other team members. Men are promoted faster and more often. Ultimately, the privilege men, particularly white men, still have within our profession is difficult to reconcile, and to me, despite my empathy, trumps their minority status.

As a student at NYU, the most active group at my school was Men Entering Nursing. Despite their good intentions, I could not shake my philosophical argument with the group. I keep coming back to one analogy:

Imagine that we had a student interest group for white students. Imagine that the group for white students became the most active group in the school. The group hosted events with all white presenters. The professor leading the group was friendly and available and helped you find jobs and study for tests. The group had a strong affiliation with the citywide white group, which provided excellent career guidance and networking opportunities. Of course, non-white students would be allowed as well, if they wanted to join the group and enjoy its networking and academic benefits. Some non-white students even sat on the e-board, but most avoided joining because they had enough on their plate trying to address non-white issues. To top it all off, one month after the election of Donald Trump, all the white students in the school (even if they weren’t Whites in Nursing members) were asked to gather after the last exam before graduation in their scrubs and take a group photo, and no one questioned it at all.

Even if white people only comprised 10% of the student and professional population, this would be inappropriate. I am a white person, and I would do everything I could to reduce this group’s influence at the university, or I would try to funnel the momentum of the group toward events and dialogue focused on privilege analysis. This is what I suggest men in nursing do in the future. 

This is my perspective, but I am open to others. I am open to being called wrong and being corrected. I am open to dialogue. Please share your ideas.

Jillian Primiano, RN, BSN, recently graduated from NYU Rory Meyers College of Nursing, where as a student, she worked with the Hartford Institute of Geriatric Nursing to develop education for geriatric care providers and improve health outcomes for older adults. Before earning her nursing degree, she studied History and Journalism at Boston University with a focus on Cold War anti-war activism, feminism and the Civil Rights Movement. After her first stint in college, she spent three years teaching English, American Studies and International Relations at An Giang University in Vietnam’s Mekong Delta, where she learned about her privilege in ways she could never have imagined.