volunteerism, service learning, and free labor

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.


covid-19 vaccine blessings

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.


Civil Unrest in Saint Louis

As a resident of Saint Louis, I have been shocked and appalled by the level of racism I’ve seen in this region. From people referring to “those people” talking about Jews to fear about traveling to perfectly safe areas of the city. The fear expressed by people of going into the city and interacting with African Americans was something I haven’t experienced in my lifetime even though I grew up in the rural South. This doesn’t even touch on the highly-segregated neighborhoods and churches.

Saint Louis has the potential to be one of the best cities in the country in which to live. It has nationally recognized universities, state of the art healthcare facilities, good transportation, excellent food, museums, parks, and affordable entertainment. Yet, we are rapidly being known for civil unrest rather than what should be the focus, civil rights, equality, and a new approach to law enforcement.

How we define civil unrest, how we define law enforcement, and how we define our personal roles and responsibilities impacts how we prepare and the seriousness with which we prepare. Civil unrest is “disharmony, expressive dissatisfaction and/or disagreement between members of a community, which leads to a situation of competitive aggression that may find expression as disruption of organization, conflicts, damage to property and injuries” (Kelen, Catlett, Kubit, & Hsieh, 2012). I must ask myself

  • What have I done to create a more harmonious environment?
  • What have I done to de-escalate potentially violent situations?
  • What have I done to recognize and confront racism?

The level of civil unrest in the United States had been relatively consistent until the 1960s when there was a significant increase with the onset of the Vietnam War. After the end of the war, the civil unrest declined but has been steadily increasing since 1980 (see Table 1).

Civil Unrest in the United States

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Adapted from Armstrong Economics and Wikipedia Contributors.

In the last few years, almost all the civil unrest in the United States has been related to police shootings of black males. I will never know what it feels like to be a black man that fears the police or a police officer that fears black men. I have never felt called to be a police officer, but respect those that are and can only pray that they exercise good judgment, self-restraint, and patience during times of civil unrest. It is not disloyal for an officer to recognize when a fellow officer failed the badge. I wonder what would happen if rather than standing in riot gear you all joined hands in prayer with the protestors and acknowledged their pain.

I am called to be a nurse and as such, I want all nurses to be prepared during times of civil unrest. I want you to also show good judgment, self-restraint, and compassion when discussing these issues at work. Many of those you work with have different experiences and may live in areas that are impacted. Be their strength. Be the kindness they need. Listen with their ears.

Please take the time to read Nurse Leaders’ Response to Civil Unrest in the Urban Core and let’s do all we can for our city and its citizens.

Blessed are the peacemakers, for they shall be called children of God. Mt 5:9


Civil Unrest and the Role of Nursing

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.