In normal times, transition-to-practice programs help new nurses gain confidence, skill, and proficiency as they move into their careers. But during the days of COVID-19, those programs can gain even more significance.
Recently, a panel discussion held at the ANCC Virtual Summit outlined how four transition-to-practice programs adapted during the pandemic. At least one program, the OhioHealth Acute Care Advanced Practice Provider (APP) Fellowship, provided staff to help care for COVID patients at the height of the pandemic.
The program, which runs roughly 10 months, prepares NPs and PAs to provide acute, critical care, and trauma services. The five-year-old program enrolls 10 APPs per year, according to Todd Fuller, MSN, ACNP, program director, based at OhioHealth Riverside Methodist Hospital in Columbus, Ohio.
The program has two parts. The first provides broad experience in critical care, while the second is reserved for the fellows to focus on a specialty once they secure a position in the system.
In March, “the two ICUs that are the main ICUs for our system at Riverside were ground zero for COVID at the time,” he notes. Facing a shortage of staff to care for COVID patients, the system called on three of the ten APP fellows to provide help in critical care. “These APP fellows are more trained than anybody to be able to best take care of these patients,” he notes. They were able to take a more independent role while also receiving supervision from their preceptors.
At the time, the staff was down three full-time employees. The APPs helped save overtime and minimize fatigue on team members. They were able to help split up extra night shifts and extra weekends and “take a lot of the burden off of the rest of the team that they were already going to be working with.”
The curriculum offers such features as a large number of CMEs, a high-tech high-fidelity simulation facility, procedure training, and an ultrasound curriculum.
Beside the OhioHealth program, the ANCC session provided information about transition-to practice programs from Huntington Hospital (Pasadena, CA), Mayo Clinic, and NewYork-Presbyterian Hospital. The ANCC Virtual Summit was held this year in lieu of the ANCC National Magnet Conference.
With no injured students appearing at their door, no pupils with chronic conditions arriving for a visit, why would school nurses be needed in a virtual learning environment?
“There’s a lot that a school nurse can do virtually,” says Linda Mendonca, RN, MSN, PHNA-BC, NCSN, FNASN, president-elect of the 17,000-member National Association of School Nurses (NASN). Even with virtual learning, school nurses provide a variety of important health services.
For instance, school nurses can provide health education to the school community, she notes. They can also monitor immunizations. Some data suggests, Mendonca says, that during the pandemic children are not being kept current on their immunizations. Whether the child is sitting in a school building or at home, school nurses need to be connected to parents to make sure that the children have all of their immunizations up to date.
School nurses can also provide referrals and connections to resources. If a family needs help due to food insecurity or access to any kind of social services, “the school nurse can be an advocate in providing those contacts and making those connections for them.”
With the fears and anxieties the pandemic causes, school nurses can also assist with mental health, “offering information to families about mental health concerns and again making contacts and referrals.”
Besides these types of assistance, school nurses, says Mendonca, can work with students with chronic health conditions, “continuing that care coordination.” They can help ensure that these students are following up on medical appointments.
As for reductions in school nurse staff, the NASN does not have specific data on that topic. Mendonca notes that in Rhode Island, where she lives, she was aware of school nurses being given pink slips in May, with some not being called back. In Florida, a story in The Palm Beach Post stated that the Palm Beach County’s Health Care District furloughed health care personnel, including school nurses. The reason cited, according to the story, was that the school year would start with remote learning with no end in sight.
At the same time, notes Mendonca, school nurses are in short supply. Statistics from a 2018 report in NASN’s The Journal of School Nursing indicate that 25% of schools did not employ a school nurse and 35% employed a school nurse only part-time.
The safety of students and staff must take priority in making the decision for a safer return to in-person learning, according to a statement released by the NASN in July. The decision-making process, the statement says, must be based on accurate public health data at the national, state, and local levels.
“School nurses want to get back to school, want to be part of that community in person, but we want to make sure that that we can do it safely,” Mendonca says. That decision to return to school needs to be based on public health data, including data at the community level, because community transmission rates vary, she notes. Also, adequate resources and plans need to be available, such as PPE, cleaning and disinfecting supplies, testing strategies and contact tracing.
“School nurses,” says Mendonca, “are the public health experts in the school community. And they are certainly going to be key to a successful reopening of schools in this country.”
If there are any silver linings to the towering black cloud that is the COVID-19 pandemic, one of them is the relaxation of restrictions on advanced practice registered nurses (APRNs) to allow these practitioners to deliver care during this health crisis. This summer, a national study is documenting those changes to APRN practice and may provide evidence to policymakers about relaxing restrictions on APRNs permanently.
Starting June 1, nurse leaders from three nursing schools in Tennessee have been conducting the National APRN Practice and Pandemic Survey to measure the impact of decisions by state leaders to waive physician oversight of APRNs during the pandemic. Ultimately, investigators hope to have data to be able to introduce in those states that still have practice restrictions evidence to “change some of those practice acts to allow APRNS to practice to the full extent of their education and licensure,” says Ruth Kleinpell, PhD, RN, FAAN, FAANP, FCCM, Independence Foundation professor of nursing education, assistant dean for clinical scholarship, professor of nursing at Vanderbilt University School of Nursing. Kleinpell is one of the principal investigators for the study.
Other principal investigators are Wendy Likes, PhD, DNSc, APRN-BC, FANNP, dean and professor of the University of Tennessee Health Science Center College of Nursing; Carole R. Myers, PhD, RN, FAAN, professor at the University of Tennessee, Knoxville; and Mavis Schorn, PhD, CNM, FACNM, FAAN, FNAP, senior associate dean for academics at Vanderbilt University School of Nursing.
The National APRN Practice and Pandemic Survey runs through the end of August.
So far, over 9,000 APRNs have responded from all 50 states, notes Kleinpell. Of those, 60% to 70% of the respondents report that they have provided care to COVID-19 patients. Some 86% of respondents are nurse practitioners; nurse-anesthetists, nurse-midwives and clinical nurse specialists also have responded.
From State to National
Initial discussions for the survey began when the governor of Tennessee issued an executive order that released some practice restrictions on APRNs, such as a collaborating physician not having to conduct an on-site visit, says Kleinpell. This led to interest in conducting a survey in Tennessee. After further discussions with various organizations, including advanced practice nurse societies, the survey expanded to a national scope.
Across the country, you’ll find a patchwork of suspended and waived regulatory restrictions on APRN practice, detailed in a map from the American Association of Nurse Practitioners. In five states, notes Kleinpell, executive orders temporarily suspended practice requirements; in 16 states, select practice agreement requirements were waived. Some 22 states have adopted full practice authority licensure laws for nurse practitioners.
The study will look at the impact of these changes during the COVID-19 pandemic, says Kleinpell. It will compare states that have full practice to states that have restricted or reduced practice to see what practitioners are reporting not only with respect to the impact on the pandemic but also impact on practice in general, she notes.
When the results are available, the investigators plan to publish their findings and provide state-based summaries. Those results could be available in September or October.
Broadening Patient Access
“Ultimately we would like to have data to be able to substantiate some policy changes at the state level, particularly in those states that continue to have restrictive practices or practices that are burdensome to APRNs,” says Kleinpell. In states that don’t have restrictions, “the APRNs are able to practice based on their licensure and education, which is really how it should be in all fifty states. We’re seeing undue burden not only on the practitioner but on the ability for patients to have care access.”
When it comes to caring for patients suffering from COVID-19, nurse practitioners (NPs), as you might expect, are making a major contribution.
Some 61% of NPs are treating patients who have been diagnosed with COVID-19, according to a recent survey from the American Association of Nurse Practitioners (AANP). Almost as many (58%) are offering COVID-19 testing at their practices.
“It was somewhat surprising to see how many nurse practitioners are literally on the frontlines of this pandemic,” said Stephen Ferrara, DNP, FNP, of ColumbiaDoctors Nurse Practitioner Group and Associate Dean of Clinical Affairs at Columbia University School of Nursing. He is also Executive Director of the Nurse Practitioner Association of New York State and the Editor-in-Chief of the Journal of Doctoral Nursing Practice.
Barriers to Treatment
Caring for COVID-19 patients does not come without obstacles, however. NPs identified lack of testing (47%) and lack of personal protective equipment (PPE) (24%) as the top barriers to treating patients with COVID-19, according to an executive summary of the survey. The survey was conducted from May 8 to May 17, 2020 and garnered over 4,800 responses from across the country. In many locations, COVID-19 testing is limited to patients who meet a narrow set of criteria (69%).
Of note, over three-quarters of the survey respondents (79%) said they reused PPE. And more than one out of two (53%) were exposed to SARS-CoV-2 in their practice or elsewhere.
At ColumbiaDoctors, Ferrara notes that he has had to reuse PPE. Specifically, he has reused an N95 mask and changed an outer surgical mask.
The use of PPE is “probably forever changed,” said Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of AANP in an interview with DailyNurse. She notes that the CDC has provided guidance on safely reusing PPE, and that a variety of mask shapes and sizes have been approved.
As in many areas of health care, COVID-19 may lead to significant structural changes. For one thing, notes Thomas, “the expansion of the use of telehealth is going to change the landscape in which we provide health care in this country and will definitely improve access to care for all patients.” NPs, she noted, “are big utilizers of telehealth because we feel it’s important to provide access to patients wherever they are.”
Ferrara’s Manhattan-based primary care practice rapidly adopted telehealth/virtual visits for non-COVID patients, he said. The practice restricted in-person visits only to those patients with COVID-19 symptoms.
Another change involves lowering regulatory obstacles. The AANP and the general NP community, Thomas said, “call on the nation’s governors to suspend all legislative and regulatory barriers that prevent NPs from providing patients with full and direct access to all the health care services that NPs are educated and prepared to provide.”
Five governors, she said, have issued executive orders to allow NPs to practice at the top of their education and training. She hopes that these five governors “will make those executive orders permanent to change that regulatory language, and I hope that we modernize health care delivery in all the other states and allow nurse practitioners to practice at the top of their education and training.”
“Beacon of Light”
As the pandemic continues, NPs need to educate patients, said Thomas, on the importance of wearing masks to prevent the spread of COVID-19. In a July 14 statement, the AANP called on the American public to wear masks, socially distance, and wash hands. NPs, said Thomas, need to be the “beacon of light to their patients.”
You can measure the massive toll of COVID-19 in various ways: the lives lost; the jobs eliminated; the strain on the health care system. For nurses, the toll can also be measured in the emotional and mental distress and anguish they experience in caring for patients and worrying how to protect their own families. For nurses looking for resources to help with their mental health, the American Nurses Foundation in partnership with other major nursing organizations in May launched the Well-being Initiative — a set of resources to help nurses manage the stress and overcome the trauma caused by COVID-19.
“We knew that going into the pandemic nurses were already under extraordinary stress, and that this would cause more,” said Kate Judge, executive director of the Foundation, the philanthropic arm of the American Nurses Association (ANA), in an interview. “All of us are concerned that this has taken and will take a toll that we could not ever imagine on nurses and the nursing profession. We all have to do whatever we can to mitigate that.”
The Foundation partnered with the ANA, the Emergency Nurses Association (ENA), the American Association of Critical-Care Nurses (AACN), and the American Psychiatric Nurses Association (APNA) to develop the tools for the Well-being Initiative. The goal, said Judge, is to provide direct assistance that is varied in its approach. The tools include:
- Nurses Together: Connecting through Conversations: Virtual voice or video calls led be a volunteer from ENA to provide peer support and a safe space to discuss such topics as self-care, resilience and bereavement.
- Narrative Expressive Writing: A five-week program in which nurses respond to writing prompts related to COVID-19. A responder provides confidential feedback.
- Happy App: This app connects nurses to a Support Giver team member.
- Moodfit Mobile App: With this app, nurses can set and track goals for sleep, nutrition, exercise, mindfulness and other activities.
- Self-Assessment Tool: Not yet launched, this tool recommended by APNA will help nurses identify mental health needs and direct them to resources.
- Hotlines and Provider Resources: Also not yet launched, the resources will include instructions for finding a mental health provider, how to get a referral, and what to seek in a provider.
As of early June, some 800 to 900 nurses had used the tools, Judge estimates. Other resources will be coming, she says, taking into account usage data and feedback. For instance, the initiative just launched a mental health survey, “Pulse on the Nation’s Nurses.”
Judge notes that nurses are using the tools to discuss topics besides COVID-19. Nurses, she said, “are really bringing their whole selves” and talking about such issues as work-life balance and financial pressures, for instance.
The tools will continue to be offered for some time. “We know that there is an ebb and flow to this disaster,” Judge said. “We are far from through it.”