Although health workers constitute about 3% of the population in most countries, they comprise 14% of COVID-19 cases reported to the World Health Organization (WHO), and in some countries account for up to 35% of COVID cases. WHO Director-General Tedros Adhanom Ghebreyesus noted this in a September 17 statement and added, “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives.” As “one of the keys to keeping patients safe is keeping health workers safe,” on Thursday the Director-General issued a 5-point charter on healthcare worker safety in conjunction with Patient Safety Day.
The 5-point WHO charter urges its partner countries to:
1. Develop and implement national programs for the occupational health and safety of health workers
WHO recommends that education and training programs for health workers at all levels include health and safety skills in personal and patient safety and that healthcare licensing and accreditation standards incorporate requirements for staff and patient safety. Member countries should also review and upgrade national regulations and laws for occupational health and safety to ensure that all staff members have regulatory protection of their health and safety at work.
2. Protect health workers from violence in the workplace
Promote a culture of zero tolerance to violence against health workers. Labor laws, policies, and regulations need to be strengthened, and all healthcare workers should have access to ombudspersons and helplines to enable free and confidential reporting and support for any health worker facing violence.
3. Improve the mental health and psychological well-being of healthcare workers
Healthcare facilities must establish and maintain safe staffing levels, and ensure fair duration of deployments, working hours, and rest breaks. Mental and social support services, including advice on work-life balance, risk assessment, and mitigation should be readily available to all staff.
4. Protect healthcare staff from physical and biological hazards
Health care systems must implement patient safety, infection prevention and control, and occupational safety standards in all health care facilities. Facilities need to ensure availability of personal protective equipment (PPE), adequate quantity, appropriate fit, and acceptable quality. All facilities should maintain an adequate, locally held, buffer stock of PPE and provide workers with adequate training on appropriate use and safety precautions. Further, at-risk healthcare staff should receive vaccinations against all vaccine-preventable infections, and in the context of emergency response, be given priority access to newly licensed and available vaccines.
5. Connect the dots between policies on patient safety and healthcare worker safety
Institutions should integrate staff safety and patient safety incident reporting and learning systems, and define the linkages between occupational health and safety, patient safety, quality improvement, and infection prevention and control programs.
Regarding the latter point, the charter states that “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe.”
For more details on the charter see the WHO announcement, “Keep Health Workers Safe to Keep Patients Safe.”
After years of failed attempts and vociferous opposition, on August 31 California lawmakers adopted a measure to grant nurse practitioners the ability to practice without doctor supervision — but only after making big concessions to the powerful doctors’ lobby, which nonetheless remains opposed.
The bill—now being considered by Gov. Gavin Newsom—is fenced in by amendments that would stringently limit how much independence nurse practitioners — nurses with advanced training and degrees — can have to practice medicine.
Lawmakers credit these compromises, like them or not, for finally allowing them to push the issue over the finish line, capping years of political scrapping and perhaps one day altering the delivery of health care in California.
“This is not an intrusion on a hallowed profession, it’s a relief,” said state Sen. John Moorlach (R-Costa Mesa), one of four Republican senators who voted for the bill. Moorlach said the measure would get more practitioners into underserved areas that don’t have enough doctors.
“It’s like the cavalry coming up over the hill to provide reinforcements to a tired army of wonderful and overworked doctors,” he said.
California is behind most other states in empowering nurse practitioners. If the bill becomes law, the state would join nearly 40 others to grant some level of independence to nurse practitioners; 22 grant full independence, according to the American Association of Nurse Practitioners. California would have among the most restrictive policies on nurse practitioner independence in the country.
“I’m not going to say I regret any of these changes,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee and authored the bill, AB-890.
Wood opposed previous attempts to remove supervision requirements.
“I wish it could be a little less strict, quite frankly,” he said, adding that this was a reasonable compromise informed by his experiences as a dentist and what he learned from other providers.
Today, nurse practitioners must enter into a written agreement with a physician to oversee their work with patients. In exchange, physicians bill them between $5,000 and $15,000 per year, according to a report by the California Health Care Foundation and the University of California-San Francisco. (California Healthline is an editorially independent service of the California Health Care Foundation.)
“Where we are with the pandemic and the craziness of the world today, it highlights why there’s a need for this,” said Andrew Acosta, a spokesperson for the California Association for Nurse Practitioners. “The doctor shortage isn’t going away anytime soon.”
Under Wood’s measure, nurse practitioners would be able to see patients in their own practice, but only after working under physician supervision for at least three years. The bill also contains many other restrictions.
Nurse practitioners argue that the measure, even with its limitations, would ease primary care shortages, especially in rural areas — a problem the pandemic has made more stark.
Opponents, primarily the powerful California Medical Association, which is the doctors’ lobbying group, counter that stripping nurse practitioners of physician oversight would lead to a lower standard of care, and that nurse practitioners wouldn’t necessarily flock to rural areas once they’re free of physician supervision.
These arguments aren’t new in Sacramento, but lawmakers and lobbyists say this version of the bill succeeded because there are new leaders at the helm of influential legislative committees who were willing to make changes, and because the pandemic has changed health care.
“I think the legislature is starting to realize decades of evidence that nurse practitioners are safe, productive providers,” said Ed Hernandez, a former legislator who was termed out in 2018 and authored the last two failed bills. “I think the policy is finally overshadowing the politics” of the California Medical Association.
Still, the biggest difference this year is the bill itself. Hernandez’s bills, introduced in 2013 and 2015, were “clean” bills that granted independence to nurse practitioners without many requirements.
There’s nothing clean about Wood’s bill, which was heavily amended in the state Senate. Instead of simply lifting the supervision requirements on nurse practitioners, the measure imposes several hoops for nurse practitioners to jump through. Before they could practice independently, nurse practitioners would have to be certified by preapproved national nursing boards, and possibly complete additional California-specific testing if accredited out of state.
Once certified, they would have to practice under physician supervision for at least three years — up to six in some cases — before they could strike out on their own. And they would have to disclose to patients that they aren’t doctors.
The bill even prescribes a Spanish phrase for “nurse practitioner”: enfermera especializada. (Technically, this refers to a female nurse. The bill doesn’t provide the equivalent phrase for a male nurse.)
That’s not even all the amendments — and the measure wouldn’t take effect until 2023.
The requirements were inserted in response to criticism from the California Medical Association that nurse practitioners are not qualified to provide patient care without physician oversight, and that patients wouldn’t understand that they’re seeing someone with less training than a doctor, lawmakers said.
Despite the numerous amendments, the association remains opposed, saying the changes don’t address their fundamental concerns.
“We’ve increased the training required for physicians over the last couple years and now all of a sudden we’re allowing unsupervised providers to treat patients who have even less training,” said association spokesperson Anthony York.
Rounds of negotiations, major concessions and hourslong Zoom calls still could not get the doctors’ group on board, Wood said.
He said it was like chasing “goalposts that continue to move.”
“It’s very disappointing when you work with opposition and nothing is ever good enough,” Wood said. “CMA will never support this bill. They’ll never go neutral on it.”
York said that characterization is not accurate. He pointed to a different bill — SB-1237 — that would allow certified nurse midwives to attend to low-risk pregnancies without physician supervision. The association was initially opposed, but after negotiations and amendments to the bill, it changed its position to neutral. That bill is also headed to Newsom.
“You don’t have to look too far to find a case where we were willing to engage on a scope-of-practice issue,” York said.
David McCuan, a political science professor at Sonoma State University, called the association’s inability to kill Wood’s bill a political “watershed moment” for the group.
“Their M.O. for 70 years has been about blocking, stunting and preventing change,” McCuan said. “The deference toward the medical profession has changed. In that sense, it would be a momentous event if this is signed.”
Though the California Association for Nurse Practitioners is celebrating legislative passage of the measure, even in its amended form, it’s a different story at the national level. Sophia Thomas, president of the American Association of Nurse Practitioners, said in a statement that the bill is choked by too much red tape to provide any meaningful change.
“California’s so-called ‘solution,’ the flawed AB-890, would establish a cascading set of new restrictions on NP practice that would maintain California’s position among the most heavily regulated and restrictive in the nation,” Thomas said.
State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate Health Committee, said he also opposed the bill, but not simply because he is a doctor or a member of the California Medical Association.
Yet many of his objections reflect those of the association, such as concerns about training and access to care in rural areas.
He also believes independence for nurse practitioners could exacerbate inequalities in the health care system, as people with less means see providers with less training.
“People with more resources are going to go with the person they think is more qualified. That’s just the way it tends to happen,” Pan said.
California Healthline’s Angela Hart contributed to this report.
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Nurses are increasingly being forced to reuse N95 masks, sometimes for five days or longer, and growing numbers of nurses said they feel unsafe reusing masks even after they were decontaminated, according to the latest in a series of nursing surveys.
That’s the worrying message Tuesday from the American Nurses Association, which reported its latest results from 21,500 nurses responding between July 24 and Aug. 14. (The survey was sent to approximately 170,000 ANA members and 300,000 non-members.)
“It is troubling that six months — six months — into the COVID-19 pandemic, nurses continue to report that PPE [personal protective equipment] shortages persist, and reuse practices of single use PPE are on the rise, despite a lack of standard practices and evidence of safety,” said Ernest Grant, PhD, RN, the ANA’s president, which represents some four million nurses.
The answers revealed that 68% of nurses said they were required to reuse N95 masks in the two weeks before taking the survey, compared with 62% who responded in the May survey, and 58% were reusing masks for five days or more compared with 43% in May.
Additionally, 62% felt unsafe with reusing masks and 55% felt unsafe using decontaminated masks, both similar to rates found in the May survey.
One nurse in a large hospital in Texas responded that her unit was given five N95 masks in March. She said that even “to this day we’re still having to use these masks,” according to Grant.
That, he said, gives a picture of the anxiety nurses are feeling.
Because of what they consider insufficient PPE, nurses struggle with anxiety, depression, and feelings of being overwhelmed. “We feel uncomfortable and unsafe that we’re having to reuse these,” said Grant, “because there’s still no guarantee that — yes they’ve undergone decontamination, but there’s always the potential that as they are continually re-decontaminated, is there possibly a breakdown in the structure that may allow for the virus to penetrate?”
That is definitely a risk, said Tener Veenema, PhD, MPH, RN, of the Johns Hopkins Center for Health Security, during a webcast Tuesday to announce the survey results.
Decontamination procedures eventually will break down the integrity of the mask, she said. “The seal will no longer be a tight fit and the mask will lose its filtration efficiency, not only putting the nurse at risk but the patients and everyone else in that hospital or healthcare setting. This is why it’s really critical to pay attention to the science behind the use of masks and respirators and the science behind decontamination.”
Jennifer Gil, RN, who works in the emergency trauma department at Thomas Jefferson University Hospital in Philadelphia, said she and many of her nursing colleagues are operating “in crisis mode.” The situation has had an “immense personal impact to our physical and mental health as we place ourselves and our families in harm’s way.”
Frequently, Gil said, she hears comments of desperation from her colleagues, as well as herself, with words like “I am not sure how I can do this much longer” and “I never thought I would consider leaving nursing.”
Asked if the ANA has heard of nurses receiving poor quality N95 masks or fake N95 masks, Grant responded that it’s a “huge concern” that is putting lives in danger. He said the ANA hopes the Trump administration and the Coronavirus Task Force will work hard to stop those sales.
The organization has heard from nurses complaining that the batches of masks they’re provided said to be N95 are “are either counterfeit or that they’re not true N95 masks,” adding big concerns that breaks in the barrier will make it easy for the virus to enter “and infect the caregiver, and then subsequently they take it home to their loved ones, and worse yet, some of their colleagues, and some other patients that they may be caring for,” Grant said.
Hospitals and other facilities spend a lot of money on these masks that they give to their nursing personnel, only to later learn they aren’t what they thought they purchased, he said.
Veenema emphasized problems with reusing re-decontaminated N95 masks over time.
Survey data, she said, indicated nurses were being asked to reuse their N95 masks beyond the 5-day “contingency limit” specified by the CDC, which she called “very concerning.”
“Masks may be contaminated with other things than SARS-CoV-2. MRSA is in hospitals. Clostridium difficile is in hospitals. Things splash up on masks: blood, saliva, fluids. All these things were the rationale behind the single time use.”
There is no end in sight to these problems, said Grant, who predicted a mounting toll on the healthcare workforce for another six months to a year, with no reliable vaccine.
Veenema added that the problems nurses face with COVID-19 are compounded by wildfires in the West, hurricanes, and other disruptions with climate change. These “have rendered the United States vulnerable across a number of different levels,” she said, adding that the PPE shortage, at least, is correctable.
In a news release, the ANA called for federal leaders to approve full use of the Defense Production Act to increase domestic production of PPE, pass the Medical Supply Chain Emergency Act of 2020 or other legislation that achieves the same goal, and expand investment in testing and public health infrastructure.
The ANA issued its warnings as unions representing nurses have filed lawsuits and workplace complaints accusing hospitals of failing to protect workers with adequate PPE, refusing to test workers, or requiring them to return to work while still COVID-positive.
Among this year’s American Psychiatric Nurses Association (APNA) Award winners are psychiatric nurses specializing in maternal depression, suicide prevention, veteran care, elderly care, and policy-making.
In advance of the 34th Annual Conference (to be held virtually from September 30-October 4), APNA officials have announced the following 2020 award recipients:
APNA Psychiatric Nurse of the Year: Linda Beeber, PhD, PMHCNS-BC, FAANA Professor and Associate Dean of Nursing at the University of North Carolina, Chapel Hill, NC, Dr. Beeber has made notable advances in the treatment of women suffering from maternal depression. APNA officials lauded Dr. Beeber’s achievements, describing her as “Not only an effective leader, but also an inspirational role model for a new generation of clinicians, scholars, and students.”
APNA Award for Distinguished Service: Barbara Limandri, PhD, PMHCNS-BC
Professor Emeritus at Linfield College, Portland, OR, Dr. Limandri is being honored for her career as a scholar, clinician, and teacher who has mentored numerous students on their paths to psychiatric nursing degrees. Among her many achievements, Limandri is known for developing a pioneering suicide prevention training program and course for psychiatric-mental health nurses. The APNA remarks that Dr. Limandri’s “Energy to ‘unselfishly give’ to the psychiatric-mental health nursing profession is remarkable.”
APNA Award for Excellence in Practice—APRN: Michelle Giddings, DNP, PMHNP-BC, FNP-BC
Giddings, a private practitioner in Las Vegas., NV, is being honored for “Her strong advocacy, knowledge, and leadership” in the successful campaign to persuade state legislators to permit Nevada’s psychiatric APRNs to perform Competency to Stand Trial evaluations.
APNA Award for Excellence in Practice—RN: Heather McCormick, BSN, RN-BC, PHN
McCormick, a Clinical Nurse Leader specializing in psychiatric intensive care at the Redwood, CA San Francisco Veterans Affairs Health Care System, is being commended as “A key leader in creating structure for a cultural shift in which the physical, emotional, social, spiritual, cultural and age-specific needs, personal dignity, and autonomy of veterans” is supported during their treatment.
APNA Award for Excellence in Leadership—APRN: LTC JoEllen Schimmels, DNP, RN, PMHNP-BC, FAAN
Schimmels, an Assistant Professor at the Uniformed Services University of the Health Sciences, Bethesda, MD, has “written or led the writing and implementation of most policies and standardized processes related to behavioral health nurses…in military medicine.”
APNA Award for Excellence in Leadership—RN: Suzie Marriott, MS, BSN, RN-BC
As Associate Director of Nursing at Stony Brook University Hospital in NY, Marriott played a key role in implementing the “Safe Wards” model and suicide prevention programs in the UK and the US. The APNA also praises her performance at SBUH during the height of the New York pandemic: “Suzie not only worked to contain transmission in her hospital units, but also provided leadership and crisis support to staff on the medical floors impacted by the care of critically ill patients.”
APNA Award for Excellence in Education: Rosalind de Lisser, APRN, FNP-BC, PMHNP-BC
Citing her eminent “leadership as a clinician educator,” the APNA is recognizing de Lisser, an Assistant Clinical Professor at the University of California San Francisco, for her seminal contributions as a designer of Psychiatric-Mental Health Nurse Practitioner programs in California and for her work as an outstanding mentor.
APNA Award for Excellence in Research: Olimpia Paun, PhD, PMHCNS-BC
The award for Paun, a professor and Rush Alumni Nurses Association Chair in Health and Aging at Rush University, Chicago, IL, honors her achievement in building “An innovative program that focuses on the mental health needs of the dementia family caregiver population.”
APNA Award for Innovation – Individual: Georgia L Stevens, PhD, APRN, PMHCNS-BC
The APNA is hailing Dr. Stevens, Director of the DC-based Partners in Aging & Long-term Caregiving, for her outstanding achievement in her region: “Dr. Stevens’ model for discharge planning and continued care coordination for this older adult population across the state of Maryland has resulted in only a 5% re-hospitalization rate over more than 4 decades.”
APNA Award for Innovation – Chapter: APNA Arizona Chapter
The Arizona Chapter is receiving an award nod for their creation of an online book club, The APNA commends their project as “An excellent way to involve and connect chapter members who live many miles apart—and now with safe distancing this online activity is ideal!”
For more details, visit the press release for the APNA 2020 Awards.
Over the past month, a growing number of nursing associations have been calling upon members of the profession to take action against racism.
The first official remarks appeared the day after George Floyd’s death. On May 31, the Minnesota Nurses Association issued a press release stating that “nurses continue to see the devastating effects of systematic racism and oppression targeting people of color in our communities. We demand justice for George Floyd and a stop to the unnecessary death of black men at the hands of those who should protect them.”
The Board of Directors of the New York State Nurses Association declared, “As nurses, we mourn for the hundreds of Black men and women killed by the police every year, like Breonna Taylor, an EMT studying to be a nurse in Louisville, Kentucky.” The NYSNA called upon nurses to “fight against the bigotry, intolerance, and hate fueling current politics and feeding an armed white supremacist movement that threatens our democracy.”
This is “a pivotal moment,” according to ANA President Ernest J. Grant. In a June 1 statement, he urged US nurses “to use our voices to call for change. To remain silent is to be complicit.”
Calling racism “a public health crisis,” the Washington State Nurses Association said, “Racism has a 400 year history in America – and the hand of racism rests heavily on the health care system and public health. We know that people of color face systemic barriers to accessing health care and being listened to or heard. It is the reason African American women face higher rates of maternal death and why the burden of the coronavirus pandemic is falling more heavily on people of color. It is why African Americans have the highest death rate and shortest survival of any racial and ethnic group in the US for most cancers. It is why African Americans are almost twice as likely to die from a firearm than their white counterparts. And, it is why we as nurses must look racism in the face and call it what it is.”
The Oregon Nurses Association commented, “As nurses, it is our duty and our calling to protect and serve the health and well-being of the entire community. That duty extends particularly to people of color who are especially vulnerable in this healthcare system.” In an interview with Austin station KXAN, Dr. Cindy Zolnierek, CEO of the Texas Nurses Association, echoed Grant’s statement, saying, “This is core to our ethics. It’s human rights so we cannot stand on the sidelines. To be silent is to be complicit. So, we have a role in this. We have a role to play in advancing human rights – in advancing health care.”
The Kentucky Nurses Association released a seven-point action plan to combat racism both in the profession and in the culture at large. The plan includes goals such as “training for nurses regarding racial disparities,” promoting the “recruitment of African American nurses and other nurses of color to serve on boards and commissions and leadership positions within our organization as well as others that focus on health,” and the addition of “cultural competency training, bias training and disparity education in every Kentucky nursing school curriculum.”
The Massachusetts Nurses Association also spoke out: “As nurses and healing professionals… we recognize institutional racism and the systematic oppression of communities of color as both a crisis in public health and a pervasive obstacle to achieving the goals of our work in both nursing practice and in the labor movement.”
Other nursing organizations issued anti-racism action statements as well, including the American Academy of Nursing, the International Family Nursing Association, the Rheumatology Nurses Society, and the Association of Rehabilitation Nurses.
As nationwide protests sparked by the death of George Floyd enter their fourth week, the American Thoracic Society is calling for a moratorium on the use of tear gas and other chemical agents to control demonstrators.
On Thursday, ATS officials issued a statement asking law enforcement groups to stop using tear gas agents such as 2-chlorobenzalmalononitrile (CS) and highly concentrated oleoresin capsicum (OC) pepper oil due to concerns about long-term lung injury.
Concerns about the use of tear gas and other agents on the spread and severity of COVID-19 were a factor in the move, said ATS President Juan Celedon, MD, in the statement.
“The use of chemical crowd control agents is outlawed in the time of war. They cause significant short-term and long-term respiratory health injury and likely propagate the spread of viral illnesses, including COVID-19,” Celedon said.
“Based on the lack of crucial research, the escalation of tear gas use by law enforcement, and the likelihood of compromising lung health and promoting the spread of COVID-19, the American Thoracic Society calls for a moratorium of CS tear gas and OC pepper weapons use,” he added.
The statement was issued on the same day President Trump — speaking at a roundtable discussion on policing and race — praised the use of tear gas and other aggressive tactics against demonstrators in Minneapolis early in the protests, calling it a “beautiful scene.”
Sven-Eric Jordt, PhD, of Duke University School of Medicine, Durham, North Carolina, has spent years researching the impact of chemical exposures — including tear gas — on the lungs.
He told MedPage Today that a study in military recruits linked tear gas exposure to chronic bronchitis, viral respiratory illness, compromised lung function and other acute and possibly chronic lung injuries.
The study, published in the journal Military Medicine in 2014, showed that recruits intentionally exposed to CS during basic training had more than twice the risk for an acute respiratory disease diagnosis after exposure compared to before exposure.
Jordt said recent technical advances in tear gas deployment allow the gas to be dispersed over much greater areas, and the clinical impact of this wider exposure has not been studied.
Likewise, in the U.S. protests and in other parts of the world where tear gas has been widely used to disperse crowds, police tactics have changed in ways that can make exposure more problematic, he added.
“What we are seeing and what we have seen is that police are using massive amounts of these agents,” he said. “In the recent protests in Hong Kong there were days when several thousands of cartridges were used.”
He added that in many recent protests within and outside the United States, tear gas and pepper spray were deployed as a first line measure, rather than a measure of last resort.
“In U.S. cities we have seen episodes where police are boxing in protesters and then using tear gas or pepper spray when the protesters have no way out,” Jordt said.
While there are, as yet, no studies directly examining the impact of tear gas exposure on COVID-19, Jordt and Celedon both said there is cause for concern that exposure may promote SARS-CoV-2 transmission.
Someone exposed to tear gas would be likely to quickly take off protective masks due to contamination, and maintaining a safe distance from other people would probably not be their main concern, Jordt told MedPage Today.
COVID-19 patients also often report loss of sense of smell, which could increase their risk of unknowingly inhaling dangerous levels of tear gas. And tear gas makes people cough, enhancing the virus’s spread if those individuals are currently infected.
“We have seen a dramatic escalation of (tear gas) use that I fear may become normalized,” Jordt said. “We have to reassess the safety of these agents with state-of-the-art toxicological techniques.”