Nurses’ Concerns with COVID19: Update April 1, 2020


Ongoing Issues: By now, most of us know the obvious: nurses and other healthcare professionals do not have the PPE that they need to practice safely. Nurses are testing positive for COVID19. The Defense Production Act has not been activated to produce more PPE and ventilators, and nurses and other providers are even fired for speaking out about it or organizing ways to access more PPE (Doctors and Nurses Fired for Speaking Out ).

Nurses’ Skill Level: Nurses are worried about being asked to do work they aren’t prepared to do. A former student of mine, who has been in more of an administrative role, is extremely concerned with being asked to go back into a hands-on medical surgical or even ICU in a supportive role. Practicing beyond one’s skill level or expertise is just one area of concern that is likely to grow as more nurses become ill, or refuse to work, or are otherwise unable to work. 

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Volunteer calls: From California to NYC to Maine, nurses are being asked to submit their names to volunteer to work. Most of these nurses will be paid, and it is an effort to organize our resources.

Nurses on the Front Line: The stories I am hearing from nurses are war-time hell-like, maybe even worse then you have heard of if you don’t have direct contact with nurses on the front line.

An example is a story a friend of mine posted from his friend in NYC: in the ER, there may be 7-10 COVID+ vented patients waiting for ICU placement. Some patients are lying on the floor in the ER because there are no beds. People are being taken to rooms on the floors and passing away before they even get seen by a nurse on that floor. Medications like propofol, ketamine, versed, and fentanyl are being run without pumps because there are no more pumps. Supplies are running out. Med Surg nurses are being forced to run drips and vents that they have not been trained on.

Pay Issues: In Utah, nurses and doctors are being asked to take pay cuts, and there is concern that this will create a great deficit of providers in this state when professionals go elsewhere to work (Utah’s largest medical provider announces pay cuts). Meanwhile, note this lovely NYC serene skyline shot, with pay that must recognize the obvious inherent hazard pay for these positions.

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(nurses recruitment add, contact information removed)

Populations and Outcomes:

Much preventative and maintenance care for those with chronic and even acute illnesses is now taking a back seat. A positive note is that telemedicine and telehealth are being used much more widely, and this may have a favorable effect on how we care for populations in the future.

Dr. Chinn forwarded a first-hand account to me of a nurse who is working in Brooklyn. She is concerned about how this illness is impacting Latinx populations, as they are often members of “essential worker” populations, and they also live in large households. This nurse states that these patients are at higher risk for death, and often experience death with less dignity. She also sees all staff getting sick, from direct care providers to janitors, and patient care technicians.

Anecdotally, in one social media group, I heard the nurses estimating that survival rate once a patient is ventilated is only around 14-20%. This is devastating to be surrounded around so much futile care and facilitating so much end of life care without perhaps the time and space it requires to do this well. (Edited: national statistics show a recovery rate of about 50% post ventilator initiation).

Heartbreak:  I am hearing heartbreaking stories of nurses sending off their children to grandparents or ex-spouses, so they won’t be exposed in the household should the nurse become sick themselves or accidentally contaminate the household. Nurses who can’t hug or hold their loved ones are aching inside every day. Nurses dying. Nurses looking around at their colleagues and they might wonder, who will be the next to not be at work, which one of us might end up in the ICU? Nurses may know that much of the care they are providing is futile or palliative, which creates moral distress. I am very concerned when I hear of nurses working multiple shifts, with one nurse posting that she had worked 13 shifts in a row, another posting about minimal sleep, and losing 10 pounds already. They don’t have time to eat and when they go shopping, the stores are lacking in supplies. There is no question in my mind that nurses are being put at greater risk not only due to exposure, but also due to physical, mental, emotional, and spiritual stressors.

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Post-Traumatic Stress: We could say nurses are stressed, or maybe we should just be truthful and say that nurses are being traumatized. I have great fears of nurses leaving the profession after this, and I also have great fears about the health of the population in general. I am fearful for those on the front lines without access to proper PPE. This sort of chaos we are experiencing may lead to positive change eventually, but for now, it’s extremely uncomfortable, painful, confusing, infuriating, and even disorienting.

We need to take good care of ourselves and take good care of one another.

I am reaching out with loving-kindness to all nurses:

May all nurses be safe

May all nurses be at ease

May all nurses be loved

May all nurses know personal healing

Namaste

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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 with COVID19 Update: March 21, 2020


This will be a quick update to implore nurses to not use cloth masks and not call for the creation of more cloth masks. The evidence shows that they are ineffective, do not create a barrier for transmission, and may in some ways increase transmission.

We all learned in nursing school that once the mask becomes damp it’s not effective. Cloth masks will become damp within minutes and we have no evidence around if adding in a filter or other materials sandwiched between layers of cloth will help. Add to this that one then has a wet, potentially contaminated cloth mask that should likely be disposed of, but at the very least needs laundering, and it becomes clear that cloth masks are not the answer. They may indeed be harmful.

In my humble opinion: The CDC stating that bandanas, scarfs and cloth masks could be helpful when they are actually potentially harmful is reprehensible.

Please review the BMJ Open article entitled:

A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.

https://bmjopen.bmj.com/content/5/4/e006577?fbclid=IwAR2bng1KIAtVW3PjBns3usq_3tOmQG2wvYxWiSxJXdITf4uqvIuB-tMcHy4

While the ANA has called out the CDC on their call for non-evidence based protocols and statements and addressed the white house, nurses are going to have to act locally.

At the very least please contact your representatives and demand access to proper PPE, increases in manufacturing, the federal government taking more responsibility for ensuring our safety.

How can we organize ourselves around advocating for proper PPE?

 

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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Public session of the Committee on the Future of Nursing 2020-2030


The Committee on the Future of Nursing 2020-2030 will be holding a public session onWednesday, March 20, 2019, from 1:30 PM to 4:00 PM ET, online and at the National Academy of Sciences building in Washington, DC.

This committee has been tasked by the Robert Wood Johnson Foundation to extend the vision for the nursing profession into 2030 and to chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century.

Through the course of the study, the committee will meet several times. This public session is one of the many processes that the committee will use to gather information and assemble evidence that members will examine and discuss in the course of making the committee’s findings, conclusions, and recommendations. The focus of this public session is for the committee to clarify the scope of the charge with the study sponsor and initiate the process of gathering relevant information related to the study. Future public sessions will focus on specific topic areas and be conducted in other locations.

This public session will be accessible via webinar and in-person attendance (seating is limited).

Please register online by 12pm ET on March 20, 2019, to receive an email with the instructions on how to join this public session.

More information about the study can be found here.

What: Public session of the Committee on the Future of Nursing 2020-2030
When: March 20, 2019, from 1:30pm to 4:00 pm ET
Where: Online and in person at National Academy of Sciences building, 2101 Constitution Avenue, NW, Washington, DC 20418
How: Click here to register online by 12 pm ET on March 20, 2019