Evil of gunshots Violence in souls cry out - help Peace is possible
I was recently asked what I mean by social justice in nursing and public health preparedness. When I think of social justice in nursing and public health preparedness I think about the concept of a strong back and a soft front which I first read about in 2010.
We need a strong back to navigate this field of investigation and to enter into deep, transformative relationships with clients…It takes a strong back to listen, become a part of the story, be expected by the client to help (yet be uncertain just how to do so), and to sincerely proceed even in the midst of not knowing—and allow your open, soft heart to work in tandem with your strong back. The strong back provides for stillness in the face of client winds that violently shake branches but do not disturb roots. — Bein, Andrew. The Zen of Helping: Spiritual Principles for Mindful and Open-Hearted Practice (p. 10-11). Wiley Publishing.
I am reminded of my work at the Administration of Children and Families focusing on Disaster Case Management for the poor and underserved. Much of the disaster services were designed for those that have much. And many of the recovery actions focused first on the wealthy, landowners, and large businesses. For example, with Katrina and New Orleans, we saw the wealthy sections rebuilt quickly and in the poor sections there were limited attempts to rebuild. The city and Corp of Engineers blocked many efforts with justifiable reasons, but the reasons always seemed to favor those with power and wealth. We also saw generational poverty when houses were handed down without legal paperwork resulting in many not being able to even prove their home was their home.
We see it even now with COVID. We only need to look at who receives vaccines first to know that all things are not equal. Some take greater risk, but many at the top of the list had no greater risk (Congress as an example). But how many high school graduates who have to go to work every day to keep the water running, the trash picked up, the grocery shelves stocked were on any of the priority lists? What about vaccines being given out at Publix? Are there any Publix stores in poor neighborhoods?
Last week I was reminded of a strong back and a soft front listening to a talk by Joanna Macy and Joan Halifax. In short, they said we also need a focus on social action, social justice, and social transformation to eliminate institutional and structural violence. Imagine if we eliminated institutional and structural violence in the way we approach policy, education, practice, and research. What if we ask:
- How is the design and implementation of these systems keeping people from meeting their basic needs?
We know that after a disaster, or illness, the greatest needs fall in the bottom two rungs of Maslow’s hierarchy and needs and yet the majority of the resources after a disaster go to the people that have the ability to meet those needs for themselves. Thus with every disaster, those at the lower socioeconomic level, those already marginalized, those already facing discrimination have their situation exponentially exacerbated.
I don’t recall if it was Joan Halifax or Joanna Macy that ended by saying:
It is a moral imperative not to be morally disengaged.
There is nothing like having a Priest pull up your profile and then post it saying you aren’t Catholic because you love Zen to get one thinking about books to read or reread and all the reasons I love Zen. I think Richard Rohr captures it best.
- McDaniel, Richard. Catholicism and Zen, 2013
- Macinnes, Elaine. Zen Contemplation for Christians, 2003.
- Macinnes, Elaine. The Flowing Bridge: Guidance on Beginning Zen Koans, 2007.
- Kennedy, Robert. Zen Spirit, Christian Sprit: The Place of Zen in Christian Life, 1995.
- Chetwynd, Tom. Zen and the Kingdom of Heaven. Boston: Wisdom Publications, 2001.
- Eusden, John Dykstra. Zen and Christian: The Journey Between. New York: Crossroad, 1981.
- Graham, Dom Aelred. Zen Catholicism. New York: Crossroad, 1999.
- Hackett, David G. The Silent Dialogue. New York: Continuum, 1996.
- Hart, Brother Patrick (ed). Thomas Merton/Monk: A Monastic Tribute. Kalamazoo, MI: Cistercian Publications, 1983.
- Inchausti, Robert. Thomas Merton’s American Prophecy. Albany: State University of New York Press, 1988.
- Lipski, Alexander. Thomas Merton and Asia: His Quest for Utopia. Kalamazoo: Cistercian Publications, 1983.
- Kadowaki, JK, SJ. Zen and the Bible: A Priest’s Experience. London: Routledge and Kegan Paul, 1982.
- http://www.kusala.org/buddhistcatholic/bccontent1.html (dialogues between Buddhism and Catholicism)
- http://www.whiterobedmonks.org/spirit.html (information on Zen Catholicism)
- http://www.innerexplorations.com/ewtext/east-wes.htm (West-East Contemplative Dialogue)
- http://www.ignatiusinsight.com/features2005/clarkolson_cathbuddh_feb05.asp (Catholicism and Buddhism)
- http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19891015_meditazione-cristiana_en.html (Letter to the bishops of the Catholic church on some aspects of Christian meditation)
This week I had the pleasure to be a volunteer vaccinator. Day 1 I supervised nursing, pharmacy, and medical students who had volunteered to be vaccinators during their holiday break. Day 2 I was one of the people blessed to be giving vaccines to frontline healthcare workers. The entire event was well organized to make sure not a single vaccine went unused and that the vaccinators were not pulled from the frontline staff, but rather faculty and students. Everyone was prescreened and consented. They were then entered into medical records and the appointment for the 2nd vaccine schedule with an appointment card handed to each person. When each got to the vaccine station everything was triple checked and they were again ask about history of fainting or allergic reactions. Each vaccine was appropriately labeled and rechecked for dosage.
In my career I’ve been part of flu vaccine clinics and many emergency responses, but this felt different. This time the people I vaccinated were my friends, colleagues, and neighbors that had been risking their lives for others for the last 11 months. They were tired and stressed, but when the needle went in their arms it was as if months of fatigue and stress melted away. The expression was a cross between relief and gratitude. And yet, with each vaccine my sense of respect and love grew for them. They served knowing the risk and when they got vaccinated not one responded as if it were owed to them, but rather they were grateful. These men and women who had given their all for months were grateful to us because as one young man said to me, we were told that all of you volunteered your time to help us. I almost cried looking at what months of wearing a mask had done to the bridge of his nose and he was thanking of us. It gave new meaning to selfless.
When I became a nurse I felt that it was a calling. Most days I can’t imagine having ever done anything else, with maybe the exception of viticulture. I hope when you look at these physicians, nurses, housekeepers, and other frontline healthcare workers you see the love of God. They did their jobs when no one knew if there would be a vaccine. They did their jobs as people continued to not wear masks and acted irresponsibly. And, they did their jobs with inadequate PPE, squabbling politicians, policies made by people who knew and cared nothing about public health, deaths of coworkers, and through myriad lunatic conspiracy theories.
When I imagine the love of God the mental image will be of the masked face of a healthcare worker.
Most of my friends have been introduced to Prudence. She is my favorite neighbor and stops by everyday for lunch. I give her dried meal worms and she drops empty snail shells on the porch as a thank you. During this year filled with social isolation I’ve had more conversations with her than anyone else.
Today, in addition to discussing when I thought COVID vaccines would be available to the neighborhood (she thinks it is important to keep bird lovers healthy and safe) we discussed things that make us emotional. It surprised me that seeing FedEx trucks loaded with vaccine made me cry tears of joy and filled me with pride in a country that worked so hard to create it. Prudence says that is how she feels when FedEx shows up with more meal worms. But today, I was surprised that I was moved to tears watching nurses being vaccinated. I thought of my many friends that have worked tirelessly during this pandemic while people like me were safely working from home.
There are ways that all of us who were safe at home can give back to our communities. We can help our neighborhoods plan. Sometimes it is the little things we do for each other that makes us all more prepared.
Make a Plan
- Ask your family members to commit to getting vaccinated.
- Ask your pastor/priest/roshi to help spread the word and provide public information.
- Have your parish nursing community help with public messaging.
- Talk to your neighbors when you see them outside.
- Make sure older neighbors have a ride.
- Keep yourself updated on local distribution plans.
- Talk to your health care provider if you don’t know who to ask about vaccines.
- Get your students and faculty involved.
- Have a vaccine buddy you commit to go with to get vaccinated.
- Commit to being responsible for getting one additional person vaccinated.
I have never been more pleased with the healthcare community for all it is doing. I hope in 6 months I will look back and say I have never been more proud of our country as all who are able chose to get vaccinated.
My conversation with Prudence ended with her suggesting a new bowl would be a great Christmas gift since I broke the one she is using. She wanted me to tell you “Vaccines Save Lives.”
The third Sunday of Advent is a day to Rejoice. This year it feels especially true as I cried watching the first trucks loaded with COIVID-19 vaccines pull away from the facility headed toward you. I was grateful for the scientist who used their intelligence to imagine new vaccines that can be produced quickly and safely. I was grateful for the FDA that insisted on following the safety procedures even in a crisis so we could all have faith the vaccines are safe. I was grateful to FedEx, UPS, and Boyles that are doing the deliveries, and for the U.S. Marshalls that are escorting them. I was grateful for all of those that have served on the committees that planned how to distribute the vaccine when it arrives in communities all across the country. And I am grateful for all of those that are working in their communities to be advocates for vaccinations.
Two days this week I am volunteering to administer COVID-19 vaccinations. It will be the first time since March that I have been inside in a room with a large group of people I don’t know except to go to the grocery store. While I have concerns about doing indoor vaccination I think it is worth the risk to keep hospitals and communities from using nurses that are caring for patients. I also believe it is a small way to give back to all of the frontline personnel that did so much for all of us during this pandemic. When this over we owe them so very much more.
The first day I’m eligible I plan to show up, roll up my sleeve, and get vaccinated. It is important for everyone to get vaccinated. We need to reach a minimum of 70% of the population vaccinated to achieve herd immunity and that means the majority of us have to play our role as good citizens. It is what Americans do. We show up when we are needed and we come together. We see the whole as more important than any one individual. And we enter each crisis as a community. I don’t want this crisis to be any different.
To me it is simple:
- Love yourself enough to stay healthy by being vaccinated.
- Love your community enough to reduce risk and be able to fully participate.
- Love your country enough to help end this pandemic, end the isolation, and make it possible for everyone to get back to work, school, and church.
I miss seeing my friends and my students. I miss taking the time to talk to the people in the grocery store. I miss restaurants, concerts, plays, and travel. Most importantly, I miss a time when the daily news didn’t involve numbers of the dead, ICU availability, and new positive tests. I hope each of you will do your part and get vaccinated.
I know that many fear vaccinations and there have been things in our past that add to that fear. There are others that believe conspiracy theories, it will most likely be impossible to change their views. By their nature, conspiracy theorists are not rational. They can no more control their irrationality than a person who is afraid can control their fear. The difference is the person who is afraid may recognize the fear as not in their best interest, but the person that believes conspiracy theories will not. Therefore, it is important to walk with the people that are afraid and be their strength and comfort. We should not equate people who are afraid with those who buy into conspiracies. I hope that each of my friends who has influence and trust in their community will take the time and effort to walk with those that are afraid or lack trust. Lend them your compassion and your strength.
The light at the end of the tunnel may just be UPS and FedEx headlights. Give them a warm welcome and for the next few months pull to the side and let them through traffic.
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.
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.
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.
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
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.
(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.
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.