Expected to Respond: The Plight of Nurses

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From the hospital to the classroom nurses are being asked to do more. When I say asked I actually mean ordered. It really is not a choice for a nurse to care for more patients than can be done safely. It is not a choice for many to decline over time. It is not even a choice to demand proper safety equipment. As more states implement Crisis Standards of Care where does it leave the bedside nurse?

Recently, I visited a couple of emergency rooms. I had the opportunity to talk to a travel nurse. She told me she did not leave her job to be a travel nurse for the money, but rather because she was tired of being taken out of the emergency room to work on COVID units. She had only wanted to be an ER nurse from the time she was in college and that was all she had done until the pandemic. The travel agency promised her she would only be assigned to emergency rooms and they had been true to their word – hospitals take note.

The surprising thing I noticed in both hospitals was that most of the personnel were only wearing surgical masks. No one was wearing either a KN95 or an N95 even though we routinely hear from the experts that even when we are out in public we should be wearing higher quality masks. How could it possibly be that I can now order KN95 and N95 masks online, but the nurses are still not all wearing the ideal personal protective equipment in hospitals? Is it any wonder nurses are fed up and burned out?

According to a 2021 survey of nurses by the American Association of Critical-Care Nurses:

  • 92 percent of respondents said they believe the pandemic has depleted nurses at their hospitals, and because of this, their careers will be shorter than they planned
  • 66 percent of respondents said they feel their pandemic experiences have led them to consider leaving nursing
  • 76 percent of respondents said unvaccinated people threaten nurses’ physical and mental well-being
  • 67 percent of respondents said they believe taking care of COVID-19 patients puts their own families’ health at risk

Gualano et al. (2021) looked at the research on burnout in those working in emergency departments and intensive care. They found high levels of stress, anxiety and depression. Globally the rate of burnout in the emergency room and intensive care ranges from 49 to 58 percent. Sadly, this is not new. A study from 2016 showed that burnout was high in nurses due to short staffing, excessive workload, and overtime. As Lasater et al. (2021) put it, “chronic hospital nurse understaffing meets COVID-19” and the result is that half of the nurses give their hospital an unfavorable grade on patient safety and 70% would not recommend their hospital. Part of the reason is a chronic shortage of not only staff, but supplies and properly functioning equipment.

Many people want to cite a preexisting shortage of nurses for the current situation, but the truth is colleges and universities are producing record numbers of nurses that should be able to meet the need if they all stayed in nursing. The shortage that has existed for decades is not because of an inadequate number of nurses. It is due to nurses leaving the hospital and voting with their feet as their voices are not only not being heard but actively silenced.

It has been a common practice to fire or discipline nurses that spoke publicly but nurses are starting to stand their ground and take such cases to court. The federal appellate court recently ruled that firing one nurse for speaking out about safety issues violated the law. If your hospital has a policy that bars you from speaking they are going to lose in court and it is past time. Media policies are an effort to hide safety issues forced on nurses by the administration and are part of the reason hospitals have gotten by with unsafe nurse staffing and overtime requirements for years. COVID brought this to a boiling point as already overworked nurses were fired for speaking out about safety concerns.

1st Circuit panel made clear that an employer cannot bar an employee from engaging in “concerted actions” — such as outreach to the news media — “in furtherance of a group concern.” That’s true even if the employee acted on her own, as Young did in writing her letter. The key in her case was that she “acted in support of what had already been established as a group concern,” the court said.

Meyer – Kaiser Health News

Who of us will ever forget the nurse yelled at by a supervisor to take off her mask during the early days of the pandemic because it would scare the patients with absolutely no concern for the safety of the nurse or the nurse’s family. We should all be grateful that nurses went public as did so many others. It should not be the case that we are expected to advocate for the patients and ourselves only in private. We have years of evidence that does not work.

Many administrators and government officials put Crisis Standards of Care in place to help address the issues of too many patients and too little staffing and supplies. Crisis standards of care are peer-reviewed guidelines that help health care providers and health care systems decide how to deliver the best care possible under the extraordinary circumstances of a disaster or public health emergency when there are not enough resources. Indeed, they provide some limited protection in most states. However, what they continue to fail to address is the moral injury to the healthcare workers that are making decisions about life and death, quality of care, and even saying “I can’t work another shift without rest.” It makes sense to implement crisis standards of care, but two years into this pandemic someone should have addressed the long-term psychological, behavioral, social, and spiritual harm to healthcare workers when such policies are implemented.

I’m not sure how we get hospitals to move away from their profit-making business model and to a model of high-quality compassionate care, but what I do know is that what you are doing right now is not good for patients or nurses. We must all stand together and support nurses at the beside. I am curious if any nurses working in the emergency room or intensive care have had any tasks reassigned during this pandemic.

Open to the path
The sun lights the way ahead
Clear of distraction

volunteerism, service learning, and free labor

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Using Healthcare Volunteers During Disasters 

Distribution of COVID vaccines once again has me thinking about the importance of volunteerism in public health preparedness and the role of nurses in volunteering their time and talents. Volunteerism has been part of the American culture since the 1803 Portsmouth, New Hampshire fire that resulted in the first legislation that dealt with the need for emergency preparedness. Since that time emergency response has largely depended on volunteers. Following World War II, the Department of Health, Education and Welfare (1961) recognized that nurses have conflicting roles and responsibilities and the Department also acknowledged the critical need for nurses during a disaster. The government’s attempts to ensure nurses availability and willingness to respond during a disaster resulted in the recommendation to remind staff of their responsibility as public servants – all nurses were considered public servants. In today’s terms we may call them essential workers. Unfortunately, there remains little emphasis on educational training in disaster response at any level in nursing education. Despite the efforts of the AACN to include disaster preparedness in the Essentials documents there is little done to ensure schools of nursing comply.

A volunteer is any paid or unpaid person who offers to perform a service of his or her own free will. Four categories of volunteers are:  (1) professional responders, (2) trained responders, (3) citizen volunteers, and (4) spontaneous unaffiliated volunteers (SUVs). No one questions whether professional and trained volunteers should be utilized during a disaster. However, the new public health threats –pandemics; terrorism; and changing expectations of citizens –challenge the government and private sector organizations to adopt new systems that make more effective use of volunteers. I accept the premise that a large-scale disaster will require more trained professional nurse responders than are presently available. Thus it is likely, as we are seeing in the current mass vaccination campaign that there is a need to use students and faculty as volunteers.

Background 

The 9/11 attacks in 2001 and Hurricanes Katrina and Rita in 2005 forced the realization that disasters occur requiring the use of volunteers in addition to professional and trained responders, even in a country with tremendous resources, such as the U.S. The U. S. Public Health Service (USPHS) had the largest deployment of nurses in its’ history in response to the 2005 hurricanes (may have been exceeded by COVID), yet this number of deployed nurses was not adequate enough to fill the need. In addition to the USPHS, the American Red Cross (ARC), Medical Reserve Corps (MRC), and all three components of the National Disaster Medical System (NDMS) (medical teams, patient movement, and definitive care) were utilized. NDMS deployed approximately 5174 personnel, the majority of who were trained volunteers and full-time employees of the NDMS.   

In an attempt to handle the outpouring of compassion from medical personnel that wanted to help in the response to the hurricanes in 2005, the Department of Health and Human Services (HHS) created a website and process to register and credential those wishing to volunteer who were not already part of established systems such as NDMS or ARC. Through the website and phone banks over 34,000 people signed up to become temporary unpaid federal workers. Three thousand eight hundred forty-two healthcare personnel that volunteered were credentialed through Credential Smart in 3 weeks and over 1,200 were deployed. This is why it surprised me to get push back from nurses about volunteering to give COVID vaccines when I mentioned it online. Why was there so much desire to help during Hurricane Katrina and so much less during COVID?

Federal, state, or local, systems can be logistically difficult for volunteers. The level of protection the volunteer receives is based on the type of disaster declaration from local to federal. Moreover, states have licensure requirements for nurses to protect the safety of the public by preventing unqualified persons from practicing as a nurse. Some states offer licensure reciprocity to member compact state (e.g., Tennessee, Maryland, Virginia, etc.), while other states waive or grant licensure reciprocity for nurses during emergencies. Fortunately COVID-19 vaccines are covered countermeasures under the Countermeasures Injury Compensation Program (CICP).

Liability Concerns 

An important consideration for nurses who volunteer is legal liability. In addition to licensure and scope of practice issues nurses must consider basic legal liability protection. Coverage from state to state varies; some provide coverage for Tort Claims, Worker’s Compensation, and Good Samaritan laws, while others do not. Some volunteers will also be covered under the Volunteer Protection Act of 1997 (Public Law 105-19), which protects volunteer clinicians working in nonprofit organizations from lawsuits for simple negligence. Hodge (2005) identified three factors on which legal protections depend, (1) the profession of the volunteer, (2) the person or facility to which the service is being provided, and (3) the existence of an emergency declaration. During the early phases of the COVID response we say Governors doing executive orders for everything from liability coverage to changes in scope of practice.

Current Systems of Volunteer Registration 

Federal government.  HHS has the authority to hire unpaid federal employees, which provides them liability protections and resolves issues of state licensure.   

State registries. Emergency Management Assistance Compacts (EMAC) now exist in 49 states and provide a broad immunity and tort liability coverage for responders (Hodge, 2005b) and additionally provides for licensure reciprocity during a disaster declared by the governor if the nurse is responding through the EMAC. Those SUVs who responded on their own were not covered.  

One of the items authorized in the Bioterrorism Act was the creation of ESAR-VHP to address the issues of credentialing healthcare professionals following 9/11. The system has established interoperable, state-based registries of healthcare professionals who have pre-identified themselves as persons willing to respond to a disaster.  The state then has the ability to verify their credentials and training in advance. Additionally, many states have adopted a version of the Center for Public Health Law’s Model State Emergency Health Powers Act (MSEHPA) that allows for such actions as waiving state licensure requirements for healthcare personnel from other states, thus providing some level of liability protection when a public health emergency is declared. 

Hospitals. In addition to the state licensure requirements, nurses must also be credentialed by the hospital at which they will be working.  This process is very time-consuming under normal circumstances and may be impossible in a disaster . The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requires accredited facilities to have a system in place to grant privileges during a disaster. 

Professional associations. Professional associations have the ability to encourage large numbers of nurses to volunteer, but generally lack the financial resources for registries.  However, because of their leadership in the profession and ability to partner with state and federal organization, they potentially can have a significant impact.  For example, through a partnership between the Georgia Nurses Association, Georgia Nurses Foundation, ARC, Georgia Board of Nursing, and Georgia Department of Human Resources, the Georgia Nurse Alert System was developed to identify licensed nurses who have the skills to deploy during a disaster, Similar partnerships have developed in other states. Professional organizations such as the American Nurses Association (ANA) are encouraging a model state legislative act through the National Conference of Commissioners on Uniform State Laws to establish a uniform law dealing with volunteer healthcare services during a disaster. A law that addresses the licensure recognition and scope of practice issues during a disaster is definitely needed, but the National Council of State Boards of Nursing will not consider any special considerations for disasters and instead wants people to buy into their current compact and consensus models. This is not likely to happen and thus leaves us unprepared. It is also a prime example of inflexibility that still rules much of the nursing hierarchy at the state and national level.

Dependence on Volunteers

Disaster response depends on volunteers who are trained and organized through programs such as the DMATs, MRC, ARC, or local hospitals and public health organizations. Disaster response does not/should not depend on the SUVs that show up to disaster sites. These SUVs are not part of organized teams and their identification and credentials are not verified; thus, they should not respond to a disaster because they can impede the response. The MRCs are now robust and exist in almost every community. It would be helpful if as part of every nursing program students were encouraged to join one of these organizations to help ensure their personal preparedness.

The extent to which volunteers are credentialed in advance of an emergency does affect the ability of hospitals to utilize them. In response to the problems with credentialing Congress directed the HHS Secretary to develop ESAR-VHP. Nonetheless, while ESAR-VHP provides advanced credentialing verification, hospital administration is not relieved of their JCAHO requirements to credential volunteers and grant privileges based on primary source verification. The size of the disaster will likely be the deciding factor in how much information a hospital requires. The often-cited case of New York City’s ability to utilize health professional volunteers after the World Trade Center attack still remains a prime example of the inability to utilize them due to the challenges imposed when attempting to verify volunteers’ identities, licensure, credentials, and training.   

Not surprisingly, nurses are the most requested health professional for most types of disasters. A combination of modeling supported by the Agency for Healthcare Research and Quality and past experience in deployments led to estimates for the number of nurses required to respond to a disaster ranging from a low of 436 for hurricanes to a high of 507,150 for a pandemic. The federal, state, and local professional responders, such as USPHS officers and DMATs, could easily deploy 436 nurses, but the concern is for how long. All of the nurses have full-time jobs elsewhere, frequently in direct patient care settings. However, the total number of federal nurses and DMATs combined do not equal 507,150. Therefore it is necessary when considering worst-case scenarios to include citizen volunteers and to enhance the existing ability to effectively and efficiently identify, credential, and utilize those volunteers including students and faculty. 

Civic Duty

I have long recognized that I consider nursing more than a job. It is my passion and my life’s work. Nurses, physicians, and all those in healthcare that must do their jobs during this crisis do so with dedication and more than a little bravery and self-sacrifice. At this moment we are asked to help with vaccinations for our neighbor and our country. It is an opportunity to engage students in service learning.

The best way to find yourself is to lose yourself in the service of others. — Mahatma Gandhi

Serving selflessly includes taking the time to model desired behaviors we hope to instill in students. We can show this to them through service learning and shared volunteering. Service learning is a strategy that integrates community service with guided instruction and student reflection to elevate the learning experience, teach civic responsibility, and strengthen communities. The last 10 months have convinced me that it is more important than ever to come together as a community, instill in students the desire to serve humanity with shared purpose and goals, and move out of our own comfort zones. It is one thing to read about mass vaccinations in a book and another to have hands on experience.

Free Labor

It is easy for me not to be concerned about giving my time and labor for free to some of these activities. I am well paid and that pay largely comes from tuition and taxes. Many students do work to afford their education and while they may want to volunteer they may not have a lot of free time. One solution to this issue is incorporate mechanisms for student to build up service learning hours that may count for clinical time even during semester breaks. In fact, this may provide greater balance to their schedule and provide working students the same opportunities as students from privileged backgrounds. We need to find ways to be more flexible and that may take us back to liability coverage that covers students between semester breaks. As a person that worked full time while doing my undergraduate degree and my PhD I understand that work is often not optional and scholarships for nurses in graduate programs are limited. Surely we can do better.

Wear A Mask

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Over the last few weeks, I have been angered by the large number of hospitals threatening nurses and physicians for wearing masks and telling the truth. Nurses have primarily been told to remove their mask or be fired. While physicians seem to be told to remain silent about shortages and conditions or be fired and while at the same time to remove their masks. I’ve collected a large number of such stories from people I know and trust. They have come from nurses and physicians. One physician, a friend of a friend, was working in an ER and the administration told him to take off his mask or be fired. He quit on the spot rather than take off the mask. The husband of another friend is also an ER physician and he actually had to go to his car and get a mask when a symptomatic patient came in because they had absolutely no N95 masks in the rural hospital.

This was sent to me by a friend who has spent her entire career at the beside.

I can’t speak out publicly and be identified because I cannot afford to lose my job. I can tell you that nurses are being bullied not to use their own PPE especially if they are working in areas that it was previously not routinely necessary. Even nurses and therapists with asthma, COPD, immunosuppression and/or recommendations from their personal physicians are being bullied about not wearing an N95/PPE that they provided themselves. My area was recently told we “can” but are not required to wear a surgical mask after repeated complaints from the Radiation Therapists we work with that their professional body (ASTRO) is recommending they wear a mask during all patient care. However, the administration here has been “working around” the nurses in administration to roll back that protection in the name of not “wasting masks”. None of them wear masks when they come through the clinic. Combined they’ve spent almost no time in the clinic before or after this began. They act as if we are overreacting when we wear masks to work with our patients, but in the same breath tell us to stay out of the clinic if at all possible and “protect ourselves” as if our front line staff is disposable. With the transition to no visitors we have folks that counted on caregivers coming in with them that are now upset and unable to do their own intake paperwork and needing more hands on care. But the culture coming down from the top is that the front end staff are overreacting if they want to protect themselves and patients by wearing masks. I feel like we are a pressure cooker ready to go off. We have young folks that are going home to families and roommates (that are working in Walmart’s and driving busses) and they are the ones helping immunosuppressed patients with their paperwork (so much more because now they can’t have a family member to help them) and when they use a physical barrier mask they get side eye from our nurse manager (whose boss is non clinical and was on the Hoax train up until last week and still makes flippant “just wash your hands, you’ll be fine, comments”) and others. They along with the rest of the management team are hoping/thinking they will “roll back” the decision to allow our folks wear masks this week… all of this from the big executive suite where a few folks, all sitting in private offices are dictating what the hands on people can do to protect themselves. It’s just wrong. They are intentionally talking amongst themselves to reach a consensus against protecting our folks before including equally/higher ranking nurses on any conversations. At a time when nurses should be at the forefront of decision making we are being railroaded and overridden. I am the only one that seems to understand the magnitude of what we are facing. Since our doctors are a separate group they can do what they want for themselves and although they can ask that we protect the patients and employees, they have no sway.
I have been working to make sure we have local seamstresses lined up and donations of fabric surgical masks so that we have some protection. However our hospital system will not allow employees to wear them, even/especially when we are in areas that they don’t deem masks “necessary” which is almost all our front line folks in non COVID19 treatment areas. It’s incredibly short sighted. One of our employees was sent to employee health after they developed a nasty cough this week. They were told no test needed, no quarantine needed, no mask needed, they could go back to work, the cough alone was not concerning.
Thank you.

CDC Failure

The guidance on the use of masks needs to be clear for both clinicians and the public. While CDC says it has been updated that does not appear to be the case and remains so vague that there is great flexibility for facilities to do what they want. Fortunately, the Joint Commission has now been clear in their recommendation that not only should staff be allowed to wear their own PPE if they have it and the hospital is not providing it, but they refute the CDC guidance and cite evidence while admitting it is incomplete. The Joint Commission confirmed that they are receiving reports from across the country of hospitals refusing to let staff bring their own N95, surgical, and homemade masks.

Use of Mask for the Public

As bad as the CDC guidance has been for healthcare personnel it has been equally bad for the general public. Statements have ranged from it isn’t need and handwashing is adequate to masks can increase a person’s risk of contracting the disease. Both are clearly misleading. The rational was first:

  • We need to conserve the PPE for healthcare personnel and the general public is at low risk. Because the virus is spread through droplets from coughing or sneezing you would need to be within 6 feet of the person that is sick.

When it became clear that many cases were actually being spread by asymptomatic people and that the virus may linger in the air longer than they first thought they still did not change their recommendation. They did change their approach.

  • People do not need to wear a mask when outside because they will wear them improperly and may increase their risk because they will be more likely to touch their faces and it will give them false confidence.

Obviously, we all know that we need to conserve N95 and surgical masks for healthcare personnel. They are our front line and deserve all we can do to protect them. However, the government is now telling us that a minimum of 100,000 to 240,000 Americans will die and 50% to 70% of the country may contract COVID-19. Spare us the rhetoric that the risk is low. Also, don’t insult people. No one thinks a mask is a protective forcefield. What the average person feels is that even a homemade mask is better than no mask. When a homemade mask or other non N95 mask is worn and combined with social distancing, handwashing, and not touching one’s face it decreases an individual’s risk when a person must venture outside.

As the nation’s leading public health organization, the CDC should remember that education is critical. If they believe that putting on a mask makes the average citizen suddenly forgets that they should social distance, wash their hands, and not touch their face then the answer is a public service campaign to remind people. If they believe that people will wear masks improperly again education is critical and they should immediately make an infographic or short video demonstrating how to properly put on a mask, take it off, and clean it or dispose of it. The real risk would be people reusing disposable masks and/or not cleaning masks. Of course, this ignores the fact we are asking healthcare personnel to do just that. This is public health 101. Treating the public as if they lack any reasonable amount of intelligence is insulting and not helpful.

What Does the Research Show

In a Lancet article  that reviewed different countries’ use of masks and the available evidence they pointed out that “there is an essential distinction between absence of evidence and evidence of absence.” They concluded, “community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wears face masks.” A cluster randomised trial of cloth masks compared with medical masks in healthcare workers found that medical mask are significantly better and should be preferred during a pandemic for healthcare providers. However, they also pointed out that medical masks are not always an option. It was suggested that cloth mask with multiple layers and tighter weaves would be more effective than the current cloth masks that they tested.  Testing the Efficacy of Homemade Masks: Would
They Protect in an Influenza Pandemic provides some insight into what materials may be best for a homemade mask. Smart AIR took the information and put it into a useful graphic that compares homemade masks to surgical masks.

Screen Shot 2020-04-01 at 10.05.30 AM

While the graphic below also isn’t evidence it makes clear that places that routinely do wear masks have fewer cases of COVID-19. Of course, there are other confounding variables and this is just one piece of data.

Screen Shot 2020-04-01 at 9.21.55 AM

Information on Making Your Own Mask

I think everyone should take the time to make their own mask. It will serve as a reminder that we are in a battle to save lives. It will remind us that in many poor countries this is all they have when they care for patients. It will give children a craft project while they are out of school that can be used to teach science, health, public safety, social responsibility, and even math. And most importantly, it may give you just a little extra protection when you absolutely must go out.

Making your own mask is not that difficult for anyone with basic sewing skills.  I’ve provided a couple of links that have instructions.

I wish you all good sewing.

There is No Greater Day to be a Nurse

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This morning many of our neighbors woke up without jobs for the first time in their adult lives. They have worked hard to learn a trade, build a business, and build a comfortable life. Due to no fault of their own, they are worried that they will now lose it all. It is new to them because they have always believed in the American dream that through hard work and perseverance they can succeed.

Nurses, physicians, and all those in healthcare that must do their jobs during this crisis do so with dedication and more than a little bravery and self-sacrifice. Sadly, a couple of days ago I saw a post by a nurse practitioner that suggested he should get paid “hazardous duty” pay if others are being paid to work from home. I, of course, replied that he was doing his duty… I’m sure he isn’t the only one that has had a similar thought, but we should work to dispel such ideas.

As nurses, we should be thankful that we are getting paid to do the job we love. At this moment we are asked to do it for our neighbor and our country. When others are worrying about how they will pay their bills, feed their children, and recover when this is over none of us face those concerns.

Once in a lifetime, if we are lucky, we are given the opportunity to serve selflessly. Don’t sully it by making this calling about money.

The American dream will live again in others because you see them through this difficult time and provide them the care they need to recover. There is no greater day to be a nurse.

Let May Registered Nurse Graduates Practice Now

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Each May over 100,000 nursing students graduate from programs across the country. Most of those students are now being pulled out of clinical and their classes have moved online. Some are being told their graduation may be delayed. The faculty will make every effort to deliver the content, but it will not be the same as the in-person classes. As anyone who has developed an online class knows it is an extreme amount of work that can’t be done in a few days.

Considering the current 8% nationwide vacancy rate for nurses and that the additional need over the next few months may exceed 100,000 nurses, it would help with the surge needs of hospitals to grant the May graduates their degrees now and waive the NCLEX. I know that some will think this is radical and how will we ensure quality. The truth is most students pass on the first try (88.18%) and if you add a second try (72.85) it is near 100% total pass rate. While students may go back and study more they do no more clinical. Thus the clinical skills they have at graduation are the ones they will have when they enter practice even if they take the exam a second time. If we can get the students out now, it may be a substantial help to hospitals that are likely to become quickly overburdened. Additionally, most of these nurses will be in the age group less impacted by COVID-19.

A second option would be to allow them to graduate now, practice for 6 months as an RN and at the end of that time take the NCLEX. As a faculty member, I prefer option 1 because we know that the longer the student delays the NCLEX the less likely they are to pass on the first attempt. Universities are assessed based on that pass rate and it would be unfair to penalize them, or the students, as the result of a national emergency.

I can hear the uproar now from people saying they need to be oriented, we don’t enough people now, and so on. However, much of the orientation could be condensed. Much of HIPAA is waived during a public health emergency so do they really need that training right now? Most have used the electronic medical record in school, so it could be taught very quickly. They are all required to have the necessary vaccines, CPR, and many other items just to enter their clinical practice settings. The truth is there is a lot of redundancy between what a hospital requires for the new employees and what schools require for students in clinical.

It is time for the National Council of State Boards of Nursing and all Boards of Nursing to take bold action. We should think out of the box and while we are at it break it down and throw it in the recycling bin. If we continue to practice as normal and hold tight to our policies we will do more harm than good if the worst-case scenario occurs with COVID-19. It is the time to act and let our May graduates have their degrees right now. If we wait until we are facing the worst-case scenario it will be too late. We must put the patient first.

Let May graduates practice. Let them join the fight against COVID-19.

Scoop and Run: A Plan for the 4th on the National Mall

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The first time I attended the July 4th fireworks in DC it was with a friend’s family who attended every year. As we were on the metro headed to the mall she informed me that when the final volley of fireworks began to “scoop and run”. Pick up all of your stuff and run to the metro as fast as possible to be on the train that would be waiting. Otherwise, we would be stuck in the crowds for hours.

My advice to anyone attending the July 4 celebration this year is to be prepared to scoop and run. Know your exits, know where the metro is, know your way to walk across the bridge if it is too crowded and for goodness sake don’t drive. But also know where there is a safe area close to you. What shops and restaurants are open where you can get through the door and out of the crowd? Be prepared that some places in the event of mass demonstrations will go into lockdown quickly. If you are in you will stay in and if you are out you will stay out.

Events of civil unrest in cities across the United States raise awareness of injustice in our society and they appear to be on the rise. Yet, it is those moments when civil unrest occurs that we often fail to recognize the human dignity of every person. Civil unrest can lead to physical violence as it did recently in Portland. Our instinct may be to respond as we would in a disaster and seek help from police and places like the medical aid stations. However, this may be the wrong action during the unrest. Because of heightened tension between the police and the general population they may view your rapid approach as a threat rather than fear. The presence of police in the medical aid station may not be possible and even if possible, it may only attract the unrest to the area and thus be undesirable.

I doubt there will be any civil unrest at the July 4th fireworks in DC, but if I were ever going to encourage caution this would be the year. Anytime a large, nationally televised event is politicized it increases the risk of clashes. Politization may include the “baby Trump” balloon, flag burning, and white supremacists. We also know that inequalities in society, culture, and finance have resulted in civil unrest, rioting, and intentional violence throughout our history. When one group is given special privileges at an event that has always been egalatarian it increases the risk of problems.

10 tips to a safe July 4th on the National Mall

  1. Stay hydrated and be aware that there are sometimes long lines at vendors. Dehydration alters your ability to think clearly.
  2. Wear sunscreen just because I’m a nurse and we remind you of the obvious.
  3. Dress appropriately for long walks and hot weather. Running or walking shoes will be better than sandals.
  4. Bring your fanny pack first aid kit or put a small one in a bag.
  5. It is always better at large events to carry your belongings in a clear plastic tote bag so that everyone can see there is nothing of danger in it.
  6. Do not bring anything with you that could be perceived as a weapon.
  7. If you see people with weapons other than police move away as quickly as possible and notify law enforcement.
  8. Be aware of your surroundings and know where the exits are located.
  9. Do not engage people who are protesting. Even if you think you agree with them sometimes people surprise you with what offends them and when you are hot and tired your own response may even be a surprise.
  10. Be cool, be calm, be alert, be gone if trouble begins.

I hope everyone has an enjoyable July 4 and remembers that the day is a celebration of our independence. It is a time to celebrate a great nation and remember that children will be present.

Nurse Leaders’ Response to Civil Unrest requires preparation. It is a good time to go through your checklist before the events begin on July 4.

 

Book Review: Voices of the Dead

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I received a free copy of Voices of the Dead by John Babb, a retired U.S. Public Health Service, Rear Admiral. I read his first book Orphan Hero which I enjoyed, but this one is different. It is a historical novel set in 1878 and tells of Yellow Fever in Memphis and New Orlean. I could feel the humidity as I read of the nurses and physicians responding to the deadly virus and risking their lives to serve others.

There are plenty of nurse heroes in this book, but also everyone from physicians to Sisters, from Priests to Madames stepped up to help their neighbors and some lost their lives in the effort. Whether you are a lover of historical novels, or epidemiological investigations, or an infectious disease nerd this is a great book.

Of course, it could be that I liked it because it had all the things that fascinate me, steamy southern cities, infectious diseases, legislation like the Quarantine Act, selfless physicians and nurses, and the Marine Hospital Service which lead to the Commissioned Corps of the U.S. Public Health Service. It dealt effectively with the fears of quarantine and what citizens do when quarantine is ordered. In many ways, it is a case study of epidemics prior to modern healthcare.

I don’t want to spoil the book, but if you are a public health worker I think you will love it.

Academic Pet Peeve: What’s yours?

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Pet peeve of the day: careerism.

My career has been a great pleasure. I loved being a U.S. Public Health Service (USPHS) officer and I now love being an academic. The worlds have commonalities that drew me to them. They are filled with people that are dedicated to service and to making the world more beautiful. At their worst, there are too many careerists that never consider how their secrecy robs the public of knowledge.

I became a USPHS officer because I wanted to work with the poor and the underserved, but was too fearful of being poor to be a missionary or join the Peace Corps. I became an academic because I wanted to create new knowledge and share it to improve health care and quality of life.

Throughout my career, I have grown increasingly intolerant of those that take a taxpayer-paid salary or taxpayer-funded research grants and then refuse to openly share their work. Over and over I have seen people recreate the wheel because others didn’t know it existed or didn’t respect the person that created it and thus felt it necessary to recreate the work and again at taxpayer expense.

Today I heard an expert on nuclear preparedness communication hold forth on the need to, “make research accessible”. He went on to say that research cannot just be in the peer-reviewed literature. This would have had more integrity if he and most of his panelist had not prefaced their presentations by insisting that there be no photography or recording of their presentations as some of their work is copyrighted.

Hypocrisy: the practice of claiming to have moral standards or beliefs to which one’s own behavior does not conform; pretense.

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Nuclear preparedness research on how to best communicate with the public is critical to preparedness, but for it to be truly effective it must be put into practice not just at the higher levels of government, but it must get down to the workers, to the mom at home with children, or to the average nurse. As the speakers stated the average teacher or clinician doesn’t read the peer-reviewed literature. How will research get down to the bedside if researchers don’t freely and openly share their work? How will we be prepared for a nuclear event if those doing the research and government officials will not share?

If you really care about improving healthcare, making us more prepared, or creating new knowledge consider the impact on lives when careerism rules public good. We can’t let advancing a career trump the public good.

End of rant.

 

Good Nursing is Prudence

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The intellect and not our will must guide our decisions. Yet, it is often our will that gets in the way of sound reasoning. Don’t we all want what we want? Would we not prefer to get our way? I know I would and at times my own will has gotten in the way of hearing what others had to say.

When I joined the U.S. Public Health Service (USPHS) I wanted to work with the poor and underserved. I had a mental image of what that meant. Simply, it was those in poverty or homeless. It had never occurred to me to consider those in prison or detained by immigration as poor or underserved. Nor did I ever consider the disproportionate impact that disasters have on those that are poor or homeless.

Late in my career, I accepted a job with the Administration for Children and Families (ACF) working for Daniel Schneider, who is now the Executive Director of the American Conservative Union and CPAC. I was fascinated by what he described to me. He wanted an office that would address the human services needs of people impacted by disaster and especially those that were poor or marginalized. He wanted the office and programs to be built on the principles of self-determination, self-sufficiency, federalism, flexibility and speed, and support to states. Of equal importance, he wanted a close working relationship with faith-based organizations. I was free to develop it as I saw fit so long as I understood that I was fully responsible for any success or failure. It was an opportunity to combine my work in disaster management and at the same time return to working with the poor and the underserved. I was all in and then I had my first meeting with faith-based groups that worked in disasters – ouch!

The first meeting was eye-opening. It was clear that people were angry and especially the person from the United Methodist Committee on Relief. There was bad blood and before I would ever be able to make progress fences needed to be mended. Fortunately, I didn’t have to do it alone. Two amazing organizations stepped forward and offered to help. The first was Catholic Charities, USA that filled me in on what had transpired following Hurricane Katrina. While I had worked in the Office of the Assistant Secretary for Preparedness and Response since 2001 I had no interaction with the human services programs. The second organization was the American Red Cross who suggested I let them host meetings on neutral grounds. I was grateful and realized that I needed to do a lot of listening.

While I listened I also knew that good policy had to be evidence-based or adapted from a policy that has historically been effective. It could not be based on emotion or lack intellectual reasoning. I understood that there had been hurt feelings and a lack of listening in the past, but I would not ignore that there were successful programs that could serve as models. While the population served was different the goals and objectives were the same. We needed to get to mutually agreeable principles and we needed to use evidence-based policy.

The stakeholder meetings revealed that health care was largely excluded from the services offered by Voluntary Organizations Active in Disasters (VOADS) and case managers rarely had health care experience. I wanted the case managers to be nurses, but the VOADS and my contracted faith-based organization wanted them to be lay people. We compromised and had a combination of case managers we trained and nurse case managers. When all the research was completed and the program pilot tested it turned out that what was primarily needed was the lay case manager with nurse case managers to be available for people with complicated medical needs and for consultation. Because I first listened and because we were all willing to follow the evidence we ended up with a program that we could all support. You can learn more about the ACF Disaster Case Management program at: https://www.acf.hhs.gov/ohsepr/response-recovery/disaster-case-management .

I considered the development of the Disaster Case Management program a great professional accomplishment. I had an amazing team, exceptional partners, and political appointees that trusted us to do our jobs and have the best interest of the country in mind. There was mutual respect. However, the sense of professional accomplishment paled in comparison to the change in my spiritual life.

When I was in Baton Rogue with Catholic Charities, USA I was asked to stay with them at the retreat center. They gave me free access to the grounds and the chapel and said I could use it anytime. I hadn’t been to a church of any kind since my twenties and so I was amused. Then I listened as CCUSA had to remind the Catholic sisters that they couldn’t give away all of the food. I watched as CCUSA personnel and volunteers worked with compassion and patience and with their dedication exemplified what it means to serve. I, on the other hand, could only see a mission to be accomplished and my cadre of young officers as tools to accomplish it. While CCUSA saw the humanity in everyone I wasn’t even seeing it in my own people. By the time I left something had changed. I was no longer listening with my ears, but with my heart. The VOADS and the faith-based organizations had a different perspective than the government. It wasn’t about sitreps, or numbers proving the success, but rather compassionate care provided to people that were suffering.  I woke up one day shortly after our time in Baton Rogue and announced I intended to retire. Not long after the project was completed I was working for a small Catholic university where I found what I sought and though I left the university after three years what I found and what they nurtured has never left me.

Following the evidence resulted in a policy that ensured better services to the poor and underserved impacted by a disaster. Letting the spirit transform the knowledge into an accomplishment for good put the program in hands that are filled with compassion. By being open to what was good and just rather than tactically efficient government and faith-based organizations were able to bring the best of what each has to offer to serve those in need.

I am forever grateful to Dan for the opportunity, to the administration at the time for prioritizing the poor, and to Brent whose faith I am sure crafted the principles on which the program was built and through which I found my faith. The experience showed me what I lacked as a human being, what I no longer wanted to be, and a path to a more compassionate existence.

Prudence is the birth mother of all virtue.

compassion

Civil Unrest and the Role of Nursing

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The health care system must be aware of the impact civil unrest can have on the mission of providing care. We have watched, some with alarm and others with a sense of civic involvement, the incidents of civil unrest that have occurred in communities across the United States since 2014. As health care providers and administrators, we must be prepared to keep our doors open and we must know how to keep our facilities safe.

Please take the time to read

Nurse Leaders’ Response to Civil Unrest in the Urban Core

Inequalities in society, culture, and finance have resulted in civil unrest, rioting, and intentional violence throughout our history. Nowhere is this currently more apparent than in the cities of Ferguson and Baltimore. It is not the civil unrest itself, but the resulting rioting and intentional violence that can create a disaster situation. This increases the care burden of health care providers during times when the governmental structure may be overwhelmed or functioning in a less than optimal manner. Beginning with the death of Michael Brown, civil unrest over the last 2 years has necessitated a closer examination of the role nurse leaders play in preparing their staff and facilities for potential results of this civil unrest. The similarities between the results of rioting and violence and natural disaster are obvious, but the differences are significant. Without adequate preparation, providers may not offer the appropriate response. Attention to the 10 “musts” for preparedness for civil unrest will facilitate a planning process and provide for a better response and recovery when communities face these issues.