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 theJournal 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.”
How do you replenish and nourish your spirit in these unheard-of times when extreme stress is the norm?
At one hospital network located in the pandemic’s epicenter, you could nourish the spirit by accessing a brief podcast or video, or spending a few moments in a quiet room. At another hospital, you might search for meaning by consulting with a spiritual director.
“The COVID-19 crisis represents a real departure in terms of the emotional and spiritual stress on frontline personnel, especially nurses,” says Reverend David Cotton, Regional Director of Spiritual Care Services at Hackensack Meridian Health, a multihospital system serving New Jersey. Just as the system provides PPE, Reverend Cotton notes, health care providers’ emotional and spiritual needs must be cared for – “PPE for their spirit,” he says.
Hackensack’s new Spiritual Care Program provides guidance and support in areas such as grief; fear; hope; faith and inner peace; and meditation, gratitude, and purpose. Health care providers can access various resources including brief videos and podcasts hosted by clergy; inspirational writing; an email to make prayer requests; and a quiet room in each hospital. Professionals who are involved with the program include hospital chaplains, community clergy, and members of integrative and behavioral health teams.
Addressing Grief and Fear
Videos and podcasts on fear and grief, says Rev. Cotton, are among the most highly used resources by frontline staff. “Grief because they’re dealing with a whole new level of grief in the traditional sense, but also grief in the sense of loss. We’ve lost our rhythm of life. They’ve lost the way they usually do business as a nurse for 10 years or 20 years or two years. Nursing is different these days.” And fear because, for one thing, nurses may fear that they will take the virus home to their families.
Also popular are quiet rooms in each hospital, which have low lighting and soft music. “Those quiet, meditative prayer spaces are a great stress reducer and reliever,” he says. Visitors to the spaces can read scripture, pick up a religious article, or write a prayer request on a note, which chaplains will then pray over.
At Bridgeport Hospital, Bridgeport, Connecticut, a hospital of Yale New Haven Health, nurses can access a program to help them deepen their spiritual sense through the Murphy Center for Ignatian Spirituality of Fairfield University. They can take advantage of four free therapy sessions from the hospital, but then can access a spiritual director from the Murphy Center, available at no charge, according to Marcy Haley, Assistant Director at Murphy Center. No prior religious experience or background is needed. This program may extend to other hospitals that have a relationship with the Murphy Center, notes Haley.
In addition, the Center is working with Fairfield University’s Egan School of Nursing and Health Studies to develop a class on spirituality and palliative care, as well as offering pastoral support for all undergraduate and graduate nursing students, many of whom are working on the front lines.
Trauma, says Haley, has “a way of humbling all of us, and how we put those pieces back together is a spiritual journey as much as it is a physical and emotional journey.”
Millions of nurses care for the world’s patients, and millions more will be needed. This is one of the takeaways from “State of the World’s Nursing 2020,” a new report developed by the World Health Organization in partnership with the International Council of Nurses (ICN) and the Nursing Now campaign.
More than ever, the world must have nurses “working to the full extent of their education and training,” states the report’s executive summary. This report “confirms that investment in the nursing profession is a benefit to society, not a cost,” says ICN President Annette Kennedy in a press release.
Some 191 countries provided data for the 144-page report,
which provides a detailed look at the profession globally. The report sounds positive
notes, while also calling for significant improvements in some areas.
On the plus side:
Some 86% of countries have a body responsible
for regulating nursing.
Of 115 responding countries, 82 (71%) have a
national nursing leadership position to provide input into nursing and health
From 2013 to 2018, the total number of nurses
increased by some 4.7 million. The global nursing workforce is 27.9 million
nurses, of which 19.3 million (69%) are classified as “professional nurses” as
opposed to “associate professional nurses” or unclassified. As the largest
occupational group in the health sector, nursing accounts for about 59% of the
However, notable needs exist:
Despite the growth in the number of nurses, more
are needed. The report notes a global shortage of nurses of 5.9 million in
2018, which is a decrease from a shortage of 6.6 million in 2016. The vast
majority of that shortage is concentrated in low- and lower middle income
To address the shortage by 2030 in all countries,
total nurse graduates would need to increase by 8% per year on average, along
with an improved capacity to employ and retain these graduates. Without this
increase, there will be a shortage of 5.7 million nurses, primarily in Africa,
Southeast Asia, and the eastern Mediterranean.
In some regions, an aging nursing workforce poses
a threat. One out of six of the world’s nurses are expected to retire in the
next 10 years, according to a press release. “Substantially older age
structures” exist in the American and European regions.
Although nursing is 90% female, few leadership
positions in health are held by nurses or women.
Only 78 countries report having advanced
practice roles for nurses.
Of 157 responding countries, 97% report that the
minimum duration for nursing education is a three-year program.
One nurse out of eight practices in a country
other than the one where they were born or trained.
Actions to Take
To equip the world with the nursing workforce it needs, WHO
and its partners provide a series of recommendations, including the following:
increase funding to educate and employ more nurses;
monitor nurse mobility and migration and manage it responsibly and ethically;
educate and train nurses in the scientific, technological, and sociological skills they need to drive progress in primary health care;
establish leadership positions including a government chief nurse;
ensure that nurses in primary health care teams work to their full potential;
improve working conditions including through safe staffing levels, fair salaries, and respecting rights to occupational health and safety;
“The world needs millions more nurses, and we are calling on
governments to do the right thing, invest in this wonderful profession and
watch their populations benefit from the amazing work that only nurses can do,”
Kennedy is quoted as saying.
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