Nurses’ Concerns with COVID19: Update April 17, 2020


The COVID19 pandemic continues to be quite an issue in New York, with over 14,000 deaths reported. I found this link to the New York Times to be helpful in assessing where we are with official numbers of reported testing and deaths (NYTimes CVOID19), though in many states we know that testing remains very limited and accuracy of tests is still only at about 67-70%.

PPE: Nurses are still without proper PPE. While the federal government claims to have distributed millions of masks and gowns, frontline workers are still faced with shortages and putting themselves at risk. Now we are seeing surges in the cost of PPE, with costs going up over 1000%, according to a report published last week by the Society for Healthcare Organization Procurement Professionals. Competitive bidding for these supplies both internationally and within our own county has compounded the issue, and if we had federal government oversight and processes in place, it is likely these issues could be addressed in ways that would help to prevent price inflation ( CNN review of the inflation of PPE cost).

This video that appeared on CBS’s 60 minutes made it clear that nuses like New York nurse Kelley Cabrera are beginning to speak out. Nurse Cabrera works at Jacobi medical center in the Bronx. She makes the point that when nurses are required to reuse N95masks for up to 5 days, they are literally being provided with medical waste to be used as PPE. Nurse Kelley Cabrera 60 minute’s interview

Nurses Stories: Meanwhile, I have heard the stories of nurses continuing to work without proper PPE and we reultantly have high numbers of nurses testing positive in areas like Ohio.

Nurses have started to reject the idea that they be considered to be angels or heroes. They didn’t become nurses to die, and they don’t want to be martyrs. While the 7 pm clapping and cheering ritual in New York City seems to have built a community spirit, some nurses experience this differently. One New York City nurse wrote: ” I ask that you do not pity me, that you do not call me a hero. I do not wish to be made into a martyr….Clap for me and other healthcare workers at seven o’clock if it makes this pandemic feel more bearable. I concede, your cheers help us trudge on. Just know that cheers and hollering don’t change the outcome. This is my fervent plea – that we change what we can after all this is over”.

Fallen Nurses: The loss of nurses becomes hard to track as the numbers increase. NYSNA has set up a memoriam page: Fallen Nurses Memoriam

A 28-year-old pregnant nurse in the UK passed away on 4/12, RIP nurse Mary Agyeiwaa Agyapong. Her father passed away two weeks before she died. Mary’s baby daughter was delivered via cesarean section before Mary died.

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Many other nurses and hospital staff in the UK have also died (daily mail review of nurse and staff COVID19 deaths).

Two nurses in Palmetto, Florida have also died from work related exposure to COVID19. Nurse Danielle Dicensio leaves behind a 4 year old son and hubsand. Nurse Earl Bailey also worked at the same hospital, Plametto General Hospital, and he passed away from CVOID19 a few weeks ago. Both nurses complained about not having access to proper PPE, which the hospital denies (two nurses die of COVID19 ). 

A colleague of Nurse Cabrera’s (mentioned above), Freda Orcan,  who worked at Jacobihospital in the Bronx passed away March 28.

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ANA’s response to COVID19:

The Ameican Nurses Association has issued a statement that nurses should be reporting when then experience retaliation around their raising concerns regarding their personal safety in the workplace, as these are OSHA violations (OSHA and retaliation issues). While hundreds of complaints have been filed, it’s difficult to determine specifically how OSHA is responding to reports made. There is a plethora of information on their website regarding COVID19 issues (https://www.osha.gov/SLTC/covid-19/),

The ANA has created a page of resouces for nurses (ANA COVID19 page). There have developed a corona virus response fund for nurses. There is also a section about ethical guidelines for nurses that may help some in their decision making process and calls forward the bigger ethical issues that nurses are facing, and  links that show all of the steps that ANA is taking in advocating for nurses.

The latest ANA/ AHA/AMA letter witten calls for the government to address the issue of minorities and the disparities they experience with receiving adequate care for their COVID19 issues. (ANA letter to the Secretary, US Department of Health and Human Services). The letter in part reads:

“As organizations that are deeply committed to equity in health status and health care, we have long recognized differences in the incidence and prevalence of certain chronic conditions, such as diabetes, asthma, and hypertension — conditions that are now known to exacerbate symptoms of COVID-19. We also recognize that other factors, including but not limited to socioeconomic status, bias and mistrust of America’s health care system, may be resulting in higher rates of infection in communities of color. Lack of access to timely testing and treatment will inevitably lead to worse outcomes for these patients.

As America’s hospitals and health systems, physicians and nurses continue to battle COVID-19, we need the federal government to identify areas where disparities exist and help us immediately address these gaps.”

While ANA has been interacting at the national level, my perception from the nurses directly working with patients on the frontlines is that they feel under-represented and that ANA is not providing them with the voice they need. One time letters to federal authorities seem to make little measurable immediate impact. around what matters for nurses being able to practice safely. They also feel that many of the practicing nurses don’t belong to ANA exactly for this reason: that there is somehow a gap between the reality of nursing practice and the work and publications of the ANA. The crisis is far from over.

May all nurses and all beings know some peace and ease.

Nurses’ Concerns with COVID19: Update April 7, 2020


At this point, things are so disheartening for so many people. The range of nurses’ stories is so wide and varied, from OR nurses being essentially laid off due to no elective surgeries happening, to nurses being offered a lot of money to come to New York City to work.

New York State has taken the unprecedented step of merging all of its 200 hospitals into one system (New York State hospital system consolidation ). 

There’s a lot of death. One nurse told a story of how she had 10 patients in one shift and 7  of them died. In some hospitals, there is a different kind of rapid response team called, specifically for CVOID19 patients, and they are being called sometimes just minutes apart on different units throughout the hospital.

Also, nurses are working with their colleagues who end up being patients in their same units; one nurse told of their nursing supervisor being hospitalized in their own ICU, and they conjectured the supervisor most likely would pass away there.

There’s a lot of understaffing and over-working, including on the medical-surgical units. Part of this is because nurses themselves are becoming ill and unable to come to work.

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Some nurses are actually more frightened to work in the medical-surgical units because they have a lack of PPE, and all patients are presumed to be COVID19 negative. Of course, when tests come back days later, the nurses discover that they worked with these COVID19 positive patients without proper PPE. There are also many issues around HIPPA and staff not being able to find out the COVID19 status of the patients they worked with previously.

Another nurse relayed this story: he works twelve-hour shifts on a medical-surgical floor, and their usual patient load now runs from 12-15 patients, the only real charting they really do is vital signs and meds. This is possible because NYC has suspended a lot of normal operations when it comes to providing care as per the governor’s laws:

“A massive section of regulations on the “minimum standards” governing hospitals — dealing with everything from patients’ rights to the maintaining of records — has been suspended ‘to the extent necessary to maintain the public health with respect to treatment or containment of individuals with or suspected to have COVID-19’.” (read about all of the laws suspended) .

This nurse cries after every shift, and he stated his tears are so different from before, in part due to his utter exhaustion. His family and friends want him to quit, they are worried about his health, but he stated he can’t quit now, they need him too much.

Nurses are asking about ramifications of quitting their jobs; some claim that they have been threatened that they will be reported to their board of nursing for disciplinary action (this is not the reportable offense of walking out and abandoning patients, rather for resigning their position). While these threats are likely idle, some nurses are still fearful of losing their licenses.

One nurse states that she works in a COVID19 only ICU unit. She says it’s mostly completely staffed by RNs: they have no NPs, PAs, Residents, Techs, or Housekeepers. Nurses and ICU Attending and Intensivists care for the patients. Med Surg nurses act as techs and assist the ICU nurses.

Recruiting: There is still a lot of recruiting going to bring nurses to NYC. One new graduate nurse (recently licensed, with no work experience) posted on social media about being offered to be “trained” to work in the ICU in NYC. All of her travel and lodging would be covered. She would be required to work 21 days, 12-hour shifts, with no days off.  The majority of the experienced nurses tried to set her straight about why this was a really bad idea, but we have no idea if she proceeded or not.

It’s not just NYC: We now have a 54-year-old nurse in Michigan who died, Lisa Ewald.

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Unfortunately, nurse Ewald may have had some issues with initially being tested by her workplace, Herny Ford Health System in Detroit, Michigan. She was likely exposed on March 24, received her positive test on March 30, and passed away on April 3. She died alone in her home. (Lisa Ewald’s story).

Rest in Peace Nurse Ewald.

Meanwhile, more than 700 Henry Ford employees have tested positive for COVID19; 500 of the positive tests are nurses. (Henry Ford COVID19)

The field of nursing will be forever changed by this.

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 COVID19: Update March 29, 2020


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

Nurses’ Shifting Thinking About Duty To Provide Services

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

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

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

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

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

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

Is Nursing Political?

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

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

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

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

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

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

New Resources and Webinars:

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

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

Be well.

 

 

Nurses’ Concerns COVID 19: Update March 26, 2020


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

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

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

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

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

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

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

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