Nurses Must Stand Together Against COVID-19 and Unjust Demands

Nurse X quit her job as a nurse in an ER. She was wearing a N95 mask in the ER lobby. A supervisor said she didn’t need it and asked her to take it off…He told her to quit. She did. Her child needs a mother. It’s only a matter of time before you see more healthcare workers making this choice if they don’t have proper PPE.

I am hearing disturbing stories of supervisors forcing nurses to remove their masks. Nurses have always been advocates for our patients. I don’t know a single nurse that is not willing to go toe to toe with a physician, administrator, or even a family member in advocating for their patients. Yet when nurses need to advocate for themselves they would rather quit than take a stand. The fear of retaliation is stronger than the fear of being unemployed. The dirty little secret of nursing is that we have a reputation for eating our young and not standing together when a colleague is targeted by a supervisor or peer.

The Largest and Least Heard Healthcare Profession

Nursing has 3.8 million women and men many of whom now fear for their lives just by going to work. While I see physicians on the news virtually every hour of the day I have rarely seen people discussing what is happening with nurses or having nurses as guest experts. People continually vote nurses the most trusted profession, but apparently, we are not respected for our expertise. The consequence is when nurses are being forced to take off their PPE (mask) by their supervisors or be fired or threatened with being reported the general public is not hearing our stories.

Many nurses feel they cannot quit their jobs so they remove the mask knowing the risk while others quit their jobs and walk away from the work they love. I have yet to hear of one nurse that refused to take off the PPE and instead told the supervisor to fire them if that is what they must do, but they will not practice in an unsafe manner.

What many people do not realize is that many hospitals have social media policies that prohibit nurses from publicly saying anything against their employer. If the nurse does not remain anonymous they can be fired. Essentially, to be a nurse one must give up their freedom of speech. They must give up the right to safety. They must be willing to risk their lives to stay employed while apparently, the employer has no obligation to provide a safe working environment.

If we have plenty of PPE as the President says almost daily, where is it. Why are nurses and physicians being forced to wear the same N95 mask for days? Is there anyone or even a single expert or one bit of evidence that says that it is safe to wear the same mask for days? We all know the answer is no there is not.

Do Not Quit

I firmly believe that nurses should not walk away from their patients and their jobs. I also believe nurses must learn how to say NO. No, I will not take off the mask I bought because you can’t seem to find them. No, I will not move to a unit when I have health and family obligations that I made known when I was hired. No, I will not wear the same mask for days because we all know that it is not safe. No, I will not be silent if my employer will not keep me safe.

What I will do is file an OSHA complaint, write my Representative, and talk to the press. I will contact a union and ask them to help us organize. I will continue to buy my own PPE and refuse to remove it. I will speak out. I will cancel my memberships to my professional organizations if they don’t start advocating for us in a way that is visible to the country.

Nurses Must Stand Together

I  suggest that we take this opportunity to come together as one strong profession and take our place as the largest healthcare profession in the county. It is time to make our voice heard and to let the country and the healthcare system know what we expect and we expect to be safe at work. It is also a good time to change our culture and trust our colleagues as much as the public trusts us. This is not a time we can afford for nurses to quit. If a nurse is told to take off PPE then absolutely ever nurse in the facility should stand together and say either that nurse is allowed to wear the PPE or we will all quit. If we speak with one strong voice the hospitals and healthcare systems will have no choice, but to step up and keep our colleagues safe.

PPE Shortage

I keep hearing that we have a shortage of PPE. We apparently had enough medical supplies including gowns and mask to send 17.8 tons to China last month to help them, but we don’t have any to keep nurses and physicians safe. We have yet to use the Defense Appropriations Act to force companies to make more PPE. And, we have safety standards that seem to be weakened by the day. We have policies that prevent many companies from selling medical supplies to the U.S. Most significantly, we have a government that is not doing enough to address the problem.

Stand up, speak out, and be heard. Caring for patients requires healthy nurses and physicians.


Let May Registered Nurse Graduates Practice Now

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.


The Ministry of Nursing in a Time of COVID-19

I woke up this morning and said a prayer for all the nurses and healthcare workers leaving the safety of their homes for hospitals and clinics around the country. Today your practice should be guided by the science and the best available evidence. When you practice know that it is also an art and for the coming months as you pass through this difficult time help to draw a beautiful picture of compassion and love for those in your care.

One of my favorite books is Spirituality in Nursing by O’Brien. It speaks to me as a nurse and my favorite passage reminds me of what it means to care for the sick. I hope you can carry it with you as you care for those with COVID-19.

I had been invited to attend an early morning church service at “Gift of Peace,” a home for persons with terminal illness operated by Mother Teresa’s Missionaries of Charity. On arrival, I settled quitely into a back corner of the small chapel. There were no pews; the sisters sit or kneel on the floor. As I began to observe the saricclad Missionaries of Charity entering the chapel I noticed, with some astonishment, that none were wearing shoes; they were all barefoot. I knew that the sisters wore sandles when they cared for patients but these had apparently been put aside as they came to kneel before their Lord. Not wanting to violate the spiritual élan of the service, I proceeded, as inconspicously as possible, to slip out of my own sandals. Somehow, becoming shoeless in church, a condition I had not experienced before, provided a powerful symbol for me. I felt that I was truly in the presence of God, of the Holy Mystery, before whose overwhelming compassion and care it seemed only right that I should present myself barefoot, in awe and reverence. Near the end of the service, as I went forward and stood before the altar in bare feet to receive the sacrement of the Eucharist, I sensed in the deep recesses of my soul that I was indeed “standing on holy ground.” That memory will, I pray serve as a poignant reminder that whenever I stand before a suffering patient, I am there also, just as surely in the presense of God, and I must take care to remove whatever unnecessary “shoes” I happen to be wearing at the time. I  need to allow the “bare feet” of my spirit to touch the “holy ground” of my caregiving, so that I shall never fail to hear God’s voice in the “burning bush” of a patient’s pain. –Sister Macrina Wiederkehr

Nursing is your ministry. Never doubt that you were called by God to care for the sick and in the coming months, you are going to see more than you imagined. If we don’t flatten the curve you may see more than it is possible to treat. You may not be able to offer a ventilator to every person that needs one. When your heart is breaking and you are exhausted slow down and take off you “shoes” and know that in the “burning bush” that is your patient God has called you to be present at that moment. It is at that moment your art and your ministry are one with your patient. You will not be able to save them all, but they will forever know that you cared.

New York is already reaching out to retired nurses and faculty to help them with surge capacity. I believe it is time for every state to do the same and make sure they have a mechanism to identify nurses that can serve.

Patron Saints of Nurses

  • St. Agatha of Sicily
  • St. Catherine of Siena
  • St. Camillus of Lellis
  • St. Elizabeth of Hungary

Nursing Schools Closing as COVID-19 Spreads

I spent the last ten years of my U.S. Public Health Service career working in public health emergency preparedness. I was fortunate to be able to help plan for some of the issues related to surge capacity for nursing in disasters and public health emergencies. In much of our planning, we made the assumption that we would be able to add nursing faculty and students to the surge efforts. We understood that schools may close but I don’t think we believed that schools and hospitals would exclude students, especially senior students, from assisting during a national crisis.

Nursing Shortage and Disaster Preparedness

Nationwide there is an 8% RN vacancy rate. The rate is even higher in many areas and especially rural and underserved communities. Added to this the average nursing students receives virtually no training in public health emergency preparedness. However, it isn’t just RNs; When we surveyed students and administrators from across the country MD, DO, and MPH students don’t feel confident to respond and the administrators were only slightly better. Screen Shot 2020-03-16 at 1.31.42 PM

(Red = not confident, Yellow = moderately confident, Green = Confident)

Healthcare students expressed dissatisfaction in their curriculum coverage related to disaster and public health emergency preparedness. Our study found similar results to others—a combination of poor curriculum coverage of disaster topics and a lack of confidence in acting on what was learned in their future positions.  This low coverage is concerning due to documented links between disaster training and willingness to respond.

MPH students reported the most coverage and NP students the least.  However, these differences did not correlate with confidence, with NP students expressing the highest confidence in their abilities to utilize their disaster knowledge. It could be because NPs already practicing as RNs.  When we interviewed 13 expert trainers we only had one that said population health was even considered in the training they provided. In short, we don’t do adequate training in school and we don’t do it in the workplace.

Bad Assumptions

Assuming that nursing faculty and students would step up has now been proven to be a bad assumption. Nursing schools across the country are moving classes online and clinical rotations are being canceled. This may cause multiple problems.

First, some states require a certain amount of clinical to be with patients rather than in simulation. Even if the schools could add more simulation they cannot do so if students are not in residence. This will lead to a reduced graduation rate in May 2020 by thousands of nurses when we are in a crisis.

Second, if nursing students are sent home then they will not be present to assist even as a volunteer with the supervision of faculty.

Compare this to England where the National Health Service is considering temporarily registering 18,000 students to provide care on a voluntary basis.

Utilization of Volunteers

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 pandemic influenza (R. Lavin & R. Knouss, personal communication, September 10, 2005).  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. 

I’m a little concerned that we did not consider how we would allow students, especially senior students, to assist at least as a CNA during the crisis. Instead, because of the legal concerns most hospitals and schools are choosing not to have students present at all. Not only will this not aid in the response, but it is likely to delay graduations in a time of extreme need. I hope going forward we will revisit this issue and find a way around regulations that restrict licensure during public health emergencies.

 


Rending My Nursing Heart

 

Even now, says the LORD,
return to me with your whole heart,
with fasting, and weeping, and mourning;
Rend your hearts, not your garments,
and return to the LORD, your God. JL 2: 12-13

Lent begins with a reminder to rend my heart.  As I looked into the courtyard outside my office I thought it is a lot like my heart. The mess of fall leaves has not been cleaned up and with all the rain they are now a mushy mess. Daffodils and the tulip tree are in full bloom heralding the coming spring and the hope of green grass, sunny skies, and warmer weather. Yet it is impossible to enjoy the beauty of spring without cleaning up the mess of fall.

Recently, I have had two college students to contact me. Neither are current students of mine, but both wanted advice. Their requests were simple enough to answer, but in both cases I found myself thinking what they really needed was someone that could be silent and listen. It is easy to listen quietly, but it is much harder to shut down the inner speech while listening that is screaming at me that we must change our culture in nursing education.

I knew both students had the answers and what they wanted was confirmation. Largely, they wanted someone to say it was okay to challenge a faculty member. As I listened it was hard to stay true to my belief that one should always first refer the students back to faculty to work out their issues. It is good practice for professional life. It builds professional negotiation skills and it builds honest working relationships. That is what I did after listening long enough for them to find their courage.

My question to my nursing friends is why does it happen so often? Why do students fear us? We should be the model of kindness and compassion to them, but instead, it sometimes feels more like we are the inquisitors. We blindly and harshly apply rules to students. Rules that can profoundly impact their academic success. Of equal concern is that when we show them such harshness we are modeling the behavior we claim to detest.

We absolutely should challenge students intellectually and ask them to dig deeper into issues. We should ask them to think out of the box and explore options that will require hard work. But we should also make sure they know that it is always safe to challenge us. I worry that the problem is we are not comfortable being challenged. Personally, I would much rather deal with the person that challenges me to my face than the one that walks away without speaking their mind only to then complain to anyone who will listen. I wish teaching inner courage was an expectation in every class.

Maybe my heart feels like a fall mess because I haven’t done enough to change the status quo. I know I want a better environment for the young nurses we are teaching, but I need to dig deep to find what it takes to change the culture that sees conflict as win-lose rather than an opportunity to understand divergent perspectives and grow.

Relational trust is built on movements of the human heart such as empathy, commitment, compassion, patience, and the capacity to forgive… If we embrace diversity, we find ourselves on the doorstep of our next fear: fear of of the conflict that will ensue when divergent truths meet. Because academic culture knows only one form of conflict, the win-lose form called competition, we fear the live encounter as a contest from which one party emerges victorious while the other leaves defeated and ashamed. To evade public engagement over our dangerous differences, we privatize them, only to find them growing larger and more divisive.  — Parker J. Palmer


Gratitude and a Little Sarcasm on Thanksgiving

When your Dean asks you to share something you’re grateful for in a meeting there is a certain amount of internal pressure to say something. Of course, request like that cause my brain to immediately become a vast wasteland of irrelevant thoughts. Worse yet ask me when I’m working on accreditation reports and massive sarcasm floats to the top.  I remained silent for fear of saying what I was thinking,  “I’m grateful CCNE only comes every 10 years.” Ah, sarcasm my defense mechanism to sharing my true feelings.

Now that I’m home and I have a solid draft of the CCNE self-study I have time to reflect on the year and be grateful. Let me begin with the things that are truly important as I get older. I’m grateful for the scientist and the pharmaceutical industry that invented and manufactured my ACE Inhibitor, Motrin, and Tums and the federal government that provides the vast majority of the money for the research that makes such miracle drugs possible. I’m also grateful for being a nurse and having the skills to monitor my own blood pressure and adjust my meds when CCNE self-study stress causes my blood pressure to rise from the combination of stress and stress eating french fries at lunch with all the associated comforting fat and salt.

I’m really, really, really grateful that I work with nurses who by their natures are nonviolent, compassionate, and don’t harm me when I make repeated request for the same data, but divided by the various different dates that don’t align for USNews & World Report, CCNE, the Tennessee Board of Nursing, and PhD self-study and all the other people that make requests and seem to have absolutely no idea how much time all the reporting eats up.  I would be more grateful if they would all learn to share and pull the data from one source and cut it whatever way they want for themselves so I could actually focus on curriculum and making things more efficient for students and faculty.

I’m grateful to have five cats. When I get home they could care less about data. They care about food, bird watching, letting me know about all the ladybugs they found in the house, and of course standing in front of the computer screen to remind me they are much more interesting than anything on the screen.

I’m grateful for amazing friends that have stuck with me throughout my life. I’m grateful my friends are so diverse and keep me grounded in the reality that what seems true to me isn’t always true to them. Long ago I forgot what it feels like to struggle financially, but some of my friends still do and they remind me to be a good friend means to share. I’m grateful to those of color who remind me that what I experience as a white woman is not what they experience and I need to work every day to check my own privilege. I’m grateful for those that are progressive and conservative because their friendship reminds me that good people see the world differently and their difference do not mean they are any less children of God or any less deserving of my love and respect. I’m grateful to those of faith for lifting me up when I struggle with my spirituality and am grateful to those that are atheist because they remind me it isn’t faith that makes one a moral person. Friends make the world a much more beautiful place and I love them all.

It should go without saying that I’m grateful for a good job that I love, a husband who is the love of my life, a family that brings joy, and all the may blessings that I probably fail to notice every day.

Happy Thanksgiving and may you be blessed with amazing food, family, friends, and gratitude. As I enjoy a good meal I pray:

This food comes from the Earth and the Sky,
It is the gift of the entire universe
and the fruit of much hard work;
I vow to live a life which is worthy to receive it.


Are Nursing Instructors Too Harsh

It has been 30 years since I began my nursing education and I laugh about what I once found stressful, but I’m never sure if I laugh because I think it is funny or out of a stress reaction. I wonder how many nurses from my era cried over care plans/maps or a thousand pages of reading assigned in one week? How many of us went to our clinical rotation after having been up most of the night preparing all the while wondering how we would ever do this for eight patients at a time.

Six months out of school everything seemed easy. I moved from wondering how I would ever do it all to why I ever thought it was hard. Therein lies the problem. I moved from a student who felt the stress to a nurse that was thinking “suck it up”. We all survived and are better prepared to care for patients as a result of those stressful and sleepless nights. But, are we?

When are we asking too much

Having worked at four universities I’ve never made it through a year without a student expressing concern about the workload and the lack of flexibility. Usually, the concern stems from an unexpected emergency, conflicting student activity, or the need to work to help pay tuition. Much of the workload cannot be helped nor can student conflicts. There is a minimal amount of content that must be taught for a student to successfully pass the NCLEX and a minimum number of clinical hours for a student to learn the necessary skills. It is a challenge for faculty and students.

When is the extra assignment too much

I think it would be good for faculty to ask what assignments are actually necessary to facilitate learning and which actually interfere with the ability to learn. If we have students spend all their time reading and doing exercises and no time remaining to reflect on the content is it as beneficial as it could be? Increasingly I believe the answer is no, but I have not found any evidence in the nursing literature to support or refute that belief. Much like the number of clinical hours and the need for content to practice safely and effectively we don’t seem to study it.

If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions. – Albert Einstein

I have always thought it would be great to have time to sit and think about the book or the article I am reading, but even now I feel the need to push on to the next task. It is what my nursing education modeled for me?

A Chronicle article from January suggest that 5 pages were sufficient. Obviously, in nursing that is a ludicrous suggestion, but so is the belief that a student can read 500 pages in a week and have multiple assignments. I can imagine a world where we get together and coordinate reading and assignments so that it is reasonable and thus it is possible for the faculty to give more attention per assignment and the students to be able to read, think, and then apply.

What do we do when an assignment is missed

I have almost always had a statement in my syllabus that essentially says that the due date is the latest possible date due so if one is prone to illness, accidents, or the heartbreak of procrastination they need to plan ahead because late work will not be accepted. Of course, it was somewhat dishonest because I clearly intended to make exceptions for births, deaths, accidents, illness, marriages, and all manner of life events. Students are people too and life happens to them. The question is always whether to adjust the grade for the extra time that their peers didn’t get or in the case of a clinical experience whether to add extra work or a makeup day.

As I have gotten older I have mellowed. I don’t think there is any evidence that a single missed clinical day has a measurable impact on performance as a nurse. I do think that adding a makeup day or assignment unnecessarily stresses the student and the faculty member. If we can’t show that it makes a measurable difference and it clearly causes student and faculty stress then why do it?

There must be a creative way to build in a late assignment or absence without encouraging either. If you know the answer please share.