In light of Florence Nightingale’s recent 200th birthday, it’s hard not to wonder—how would our founder of modern nursing be responding to the Coronavirus pandemic? Known as the “Lady With The Lamp,” Nightingale was noted for wandering the wards of the hospital at night carrying a lamp, providing support to soldiers during the Crimean War. Advocating for basic standards of care, Nightingale believed in the importance of good hygiene and adequate nutrition but also helped improve the emotional health of soldiers by writing letters home for them. It’s easy to imagine her at the bedsides of dying COVID-19 patients, charged with the painful work of helping family members say goodbye to their loved ones over FaceTime. A natural problem-solver, we can venture to guess that Nightingale would be a leader in transforming today’s trends in how to manage the well-being of American citizens and guiding our decisions on economic closures. Nightingale faced many odds during her lifetime, but ultimately became known as a social reformer, statistician, and founder of what we know of as modern nursing today.
“God spoke to me and called me to His service. What form this service was to take, the voice did not say.”
Nightingale’s parents initially disproved of her decision to become a nurse, expecting her to marry and raise a family at a young age. In fact, she had many marriage proposals but refused them all. Nightingale had other plans and, as a teenager, believed she received a calling from God to help the poor and the sick. Nursing was not a respected profession during her time and when Nightingale arrived at the British camp during the Crimean War, doctors did not initially welcome her. However, under her leadership, Nightingale’s group of nurses transformed the conditions of the hospital and brought the death rate down from 40 to 2 percent. Like many nurses today who are rapidly becoming infected with COVID-19 from working conditions, Nightingale fell ill shortly after arriving to Crimea with brucellosis, otherwise known as “Crimean fever.” With no active treatment for the disease, Nightingale suffered its persisting effects for almost 25 years, which frequently confined her to bed due to chronic pain.
After returning home from the war, Nightingale knew there needed to be health reform for the British Army. Having kept meticulous notes on the causes of illness and death during her time at Barrack Hospital, a commission was established based on Nightingale’s statistical findings to reform military medical systems. Nightingale had a knack for analyzing data and with the help of Dr. William Farr developed the first pie charts, calling them coxcombes. These charts helped illustrate her statistical findings in an accessible way and in 1860, Nightingale became the first woman elected Fellow to the Statistical Society. As a token of gratitude for her war efforts, a fund was set up that Nightingale used to institute the Nightingale Training School in London, which opened in 1860. The school offered a formal nursing education and made nursing a respectable option for women who desired work outside of the home. Although ill and bedridden for much of her later life, Nightingale wrote almost 200 books, pamphlets, and reports over the course of her career on hospital, sanitation, and statistics and provided advice on health care issues to colleagues across the globe.
“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”
Florence Nightingale was a pioneer of nursing, leadership, and education and someone who certainly would not sit around and wait for things to blow over without taking action herself. In today’s times, one can easily imagine her as anyone from the charge nurse of an intensive care unit to an ANA president consulting with the White House team. One thing we know for certain is Nightingale would first and foremost be a patient advocate. She would not stand for a shortage of ventilators or medication for patients. If we learn nothing else from Florence Nightingale, we must remember that it is not enough just to care for our patients. We must be their voice when they cannot be heard and use actions to bring results.
Florence Nightingale, Nursing, and Health Care Today
This in-depth analysis of Nightingale's legacy goes beyond established scholarship to examine her lesser known–and arguably even more important–writings beyond Notes on Nursing. It introduces readers to the "real" Florence Nightingale who pioneered evidence-based health care, campaigned for hospital safety, promoted economic opportunities for women, and mentored two generations of nursing leaders.
Before COVID-19, Mollie Biewald, MD, was skeptical about using telemedicine for palliative care visits. But now, she has found herself holding iPads or iPhones at the patient bedside, helping families make difficult decisions.
Over the past few weeks, some of her patients — whether hospitalized for COVID or another disease — have received daily family visits via Zoom or FaceTime. When a patient is actively dying, with the family present remotely, Biewald or another clinician will often stay at the bedside, holding the device.
“It is amazing,” said Biewald, a palliative care physician at Mount Sinai Hospital in New York City. “We mostly use it to bring the family to the bedsides of patients who are otherwise totally separated from everyone they know.”
While she initially thought it would be “nothing like the real thing,” she has changed her mind, as it has enabled family members to see their loved one and be present virtually while the patient is dying.
“It’s not ideal, but the best we can do, and much better than the alternative,” Biewald told MedPage Today.
Other palliative care teams across the country similarly have taken to telemedicine to conduct advance care planning and goals-of-care conversations with patients without having to enter their hospital room or increase the number of personal contacts by providers. Professional volunteers from around the country have also helped with palliative care consults and virtual office hours in support of providers in New York City.
More than other medical specialties, palliative care is built on personal contact, conversation, and relationship-building — supporting patients and families to clarify their values and define their treatment preferences in the face of serious illness, whether they are in the hospital or the community.
Michael Rabow, MD, of the University of California San Francisco, heads a busy outpatient palliative care clinic that was an early adopter of telemedicine, providing about half of its visits remotely.
“After this crisis ends, whatever new normal looks like, the numbers for tele-visits may go down, but not to where they were before,” Rabow said. “I think a lot of providers have recognized that telemedicine can work in palliative care, but the ideal balance between remote and in-person visits is not yet known.”
Palliative care professionals in some cases could be brought in virtually to assist other clinicians in discussions about whether a COVID patient with comorbidities whose condition is getting worse would want to go on a ventilator, given the poor outcomes. Might they consider the alternative of dying without the vent, perhaps in a private hospital room or at home, supported by hospice care?
“The biggest benefits of palliative care consultations are further upstream, when people can consider in advance what would be important to them in a situation like that,” Rabow said. If they understand the ramifications and don’t want to die of COVID in the hospital, alone and on a ventilator, then they may want to express other choices now, through an advance directive.
For Michael Fratkin, MD, founder and CEO of ResolutionCare Network, a community palliative care service headquartered in Eureka, California, telemedicine is not only essential to delivering palliative care services to seriously ill patients in the current crisis, he thinks it provides a better medium, in many cases, than in-person visits, given the nature of the conversations.
Prior to March 16, when California shut down in response to COVID-19, ResolutionCare Network was conducting 30% to 40% of its local patient encounters by video on a computer, iPad, or smart phone, and the rest in person. Since then, its team of four physicians, nurses, social workers, and a chaplain, mostly working from their own homes, has provided 100% of visits remotely to a caseload of 200 patients.
What happens in these virtual meetings with seriously ill patients and their caregivers? Trust building, goal setting, shared decision making, advance care planning, symptom management, and the identification of social determinants of health, caregiver adequacy, and available community resources, Fratkin said. What makes it better is the relational quality of the encounter.
“We haven’t had a single situation that required an exception to our no-home-visit policy,” he added. Some patients have been referred to their primary care physician, to urgent care, or to the hospital for more acute needs. Precautions are practiced even though Eureka to date has had few COVID-infected patients. “We are prepared to go to the home, dressed in personal protective equipment (PPE), but we just haven’t needed to.”
Satisfaction with this approach among staff, clients, and referral sources is almost universal, Fratkin said. “Even for the resisters. They got over it quickly.” Advantages include the pragmatic — such as reduced risk of exposure to the virus. People don’t have to get up, get dressed, drive to the doctor’s office, and sit in a crowded waiting room; staff don’t have to drive on back roads to the patient’s home, he said.
“And it prevents a feeling of ‘home invasion’ by our staff. Everything we wish to see in the home has to be shared by consent of the patient. It’s a more balanced power relationship, without giving up anything in terms of trust-building or the intimacy of the interaction.”
Most of the patients Fratkin’s company serves are Medicaid-covered, often buffeted by housing and food insecurities, substance abuse, mental health issues, and trauma-informed losses, he said. “Because of our experience in telemedicine, we are being asked to be part of conversations aimed at getting patients out of the hospital and keeping them out.”
“Telemedicine is providing insights into all the ways to improve healthcare,” Fratkin said. It took the virus to change the game. “This experience with COVID will take us past the tipping point, to where the public better understands what palliative care is all about.”
By Larry Beresford, MedPage Today. Article published courtesy of MedPage Today.
As staff struggle to cope with the working conditions created by the COVID-19 crisis, nursing leaders may find themselves in new territory as they strive to support them. Eloise Cathcart, MSN, RN, FAAN, director of the nursing administration program at NYU Rory Meyers College of Nursing, has some valuable tips on leadership during the pandemic. She observes that this is a uniquely difficult time: “No nurse manager practicing today has experienced anything like the coronavirus pandemic… None of us has managed this degree of chaos, complexity, and uncertainty before so, in a sense, we’re all new nurse managers trying to find our way.”
1: Embrace your leadership role, even if you’re uncertain about what to do
Worried that you’re not ready to take on the challenges of leading in the middle of a crisis? As we have often been told, the current situation is “unprecedented.” Keep your focus, and remember that you’re not alone. Remarking that “no one has done this before,” Trust your clinical skills and judgment, Cathcart counsels, but “Don’t hesitate to reach out to a more experienced nurse manager colleague or your director for help.” Be sure to establish a supportive presence, she recommends, and “be visible and available to engage in patient care so that you can assess how individual members of your team are coping.” This will also keep you up to speed on the particular needs of COVID-19 patients and help you to uphold the highest standards of care.
2. Now, more than ever, your comportment is your most important management tool
Healthcare workers are especially vulnerable to a virus like COVID-19. While fear is a natural response, though, it has to be managed and overcome. Like an officer on a battleground, the nursing leader’s behavior and demeanor exerts a powerful influence on the esprit de corps. Be present and connected to your staff, Cathcart says, and approach them with empathy and understanding: “As you strive to meet individuals where they are emotionally, it’s okay to relax your boundaries a bit so you can connect with your staff on a very real and human level. This is a time to give people more room to express their feelings.”
3. Express a vision for the day and acknowledge short-term wins
At the start of each shift, show respect for the courage of your team, and remind them of their duty to keep themselves and their patients safe. Cathcart also notes, “Staying focused on the present and acknowledging the small wins that come from a team working together to do their best can help bolster staff morale.” However, she urges leaders to remain grounded and realistic, warning that “there’s lots of difficult news, but denying reality makes people assume you’re out of touch.”
4. Keep the voice of the clinical nurse in the conversation
Finally, Cathcart emphasizes how important it is for nurses to make their voices heard, and to use this experience to reaffirm their passion for nursing. A leader should recognize that the clinician’s voice is vital: “Intentionally creating opportunities for nurses to speak about their experiences will validate the value and worth of the incredible work they’re doing and lessen the tremendous burden they carry.”
Leaders working on the front lines are in an excellent position to hone their abilities and learn to excel. “Ask yourself,” Cathcart suggests, “how you’ve learned to focus your mind, control your stress, excel under pressure, work through fear, build courage, and adapt to adversity. Knowing these things about yourself can help you develop the spiritual and ethical resilience that will form you into a great leader.”
Doctors, nurses, and health care providers are on the front lines of the coronavirus pandemic, providing care and saving lives. Given how little is known about the virus, and how contagious it appears to be, many health care workers are understandably nervous about contracting the disease or bringing it home to their loved ones. Whether you’re a nurse in the ICU or a home health care worker in a senior facility, here are seven precautions you can take to combat COVID-19 and protect yourself, your family, and your friends.
1. Make sure your facility is following CDC guidelines.
At this point in the coronavirus epidemic, your facility should already be following the guidelines from the Centers for Disease Control (CDC). This includes measures such as identifying airborne infection isolation rooms (AIIR) or negative pressure rooms for quarantine and screening. Another important measure is outlining staffing protocols to facilitate the care of patients with COVID-19. Since developments are changing so rapidly and new research is proceeding apace, you should double-check that your facility is staying up to date with the most current findings. You can find more guidance from the CDC’s centralized portal.
2.Observe proper PPE protocols.
Personal protective equipment (PPE) shortages are a sad reality in some areas, even as companies and individuals race to make more masks, face shields, gowns, and gloves. As much as possible, you should wear PPE and follow safety protocols, including proper hand sanitation. Sanitize your hands, step into your isolation gown, put on your N95 respirator, add your goggles or face shield, wash or sanitize your hands again and put on your gloves. Then, you may finally enter the patient room. Before exiting the room, remove the gloves and gown and dispose of them. After exiting the room, perform hand hygiene before and after removing the face shield and mask.
3.Watch yourself for symptoms.
Health care workers are unfortunately at a greater risk of catching coronavirus, especially if they are working directly with patients who are ill with COVID-19. Watch yourself carefully for symptoms such as fever, cough, and shortness of breath within 2-14 days of exposure. Symptoms present very differently from individual to individual, and you can also be asymptomatic while carrying the virus without knowing it. You can measure your temperature to make sure that you’re not sick if you think you might have been exposed. If you start exhibiting symptoms, it’s imperative to get tested immediately. You don’t want to infect otherwise healthy patients, so the safest action you can take is to self-isolate and wait for your test results.
4. Educate your patients.
Yes, health care providers can spread the coronavirus — and so can your patients. In fact, the vast majority of people have picked up the virus from other civilians in perfectly ordinary situations, like going to the grocery store. Talk to patients about the importance of self-isolation and following CDC guidelines, such as not touching their faces, washing their hands properly for at least 20 seconds, and limiting trips outside the house. Make sure that your patients are only coming in for an appointment if absolutely necessary. If there’s any chance they have coronavirus, even if their symptoms are mild, it could be best for them to ride it out at home rather than to come in and potentially infect other people. As always, make sure all patients consult with their health care providers about any such decisions.
5.Leave the germs at work.
Bring a set of clean clothes and shoes with you to work in a sealed plastic bag. At the end of your shift, perform hand hygiene and change into the new clothes and shoes. Place your scrubs in another sealed bag to bring home with you and don’t put the dirty clothes in the same bag as the clean clothes if you plan to reuse them. If you can, leave your slip-resistant shoes in your locker so you don’t have to take them home with you. Once you leave the hospital, wipe down your cell phone, pager, and other personal devices with disinfectant. You might also want to disinfectant the door handles, steering wheel, and other high touch areas in your car.
6.Clean your scrubs and shoes.
At home, leave your shoes outside the door. Take off your clothes and put them in the washer immediately alongside your nursing scrubs. Wash the clothes on the hottest setting possible with plenty of detergent. If you want, you can also add bleach to the wash cycle. Dry the clothes for at least 30 minutes on the hottest setting available. If your shoes are made of a hard material, wipe them down with disinfectant after each shift. If they’re not, wash them periodically in a separate load.
7. Protect your family.
Even if you’re not currently exhibiting symptoms, if you work in a role that exposes you to patients that likely have coronavirus, you might want to self-isolate from your family. You can isolate yourself in your own living space, but you’ll need to sleep in a different bedroom, use a different bathroom, and eat your meals separately from the rest of your family. If your current living arrangement doesn’t allow you to do that, some hotels and short-term rentals are offering accommodations to health care workers for drastically reduced rates so they can keep their families safe.
Following these guidelines and erring on the side of caution will cut down on your odds of spreading COVID-19 or catching it yourself. Stay abreast of the latest guidelines and do everything you can to leave the germs at the hospital.
Tending to anxious parents is a daily challenge of nursing in a pediatric hospital, but how do you cope when you’re the anxious parent and the patient is your own 8-year-old daughter? At American Family Children’s Hospital (AFCH) in Wisconsin, Nurse of the Week Windy Smith, MSN, RN is in this strange position while her daughter Ellie is undergoing chemotherapy for Langerhans cell histiocytosis, a rare cancer that causes tissue lesions.
While Langerhans cell histiocytosis can damage organs or cause tumors to form, most patients can be expected to survive. When the illness is more extensive, though, treatment can be grueling, and Smith’s little girl has been undergoing a year-long course of steroids, antibiotics, and hospital visits for chemotherapy treatment. Fortunately for Ellie and her mom, however, the 8-year-old’s favorite nurse has been available to provide care. Smith, a managing nurse at AFCH, says that Ellie “has to get labs before her chemotherapy and she has wanted me. She has a port in her chest, and so she has wanted me to access her port.” Her daughter explains her preference simply: “[It’s] just cause I sort of trust you more.” Smith reflects, “It’s like a heart-breaking privilege I have.”
Being able to participate in your own child’s treatment is indeed a privilege, but the experience has nonetheless been extremely stressful. “It’s all-consuming,” says Smith. “And while I know Ellie’s treatment is essential, it breaks my heart every time I access her port.” Their mother-daughter bond has helped to sustain them when things are hard. Noting that May is Mental Health Awareness Month, Smith remarks, “We have had some challenges with some depression and anxiety. It took us a while to actually start talking about it, start talking about feeling sad and feeling kind of angry about some of these things, but it’s really normal, so I’m glad she felt comfortable to open up and talk to us about it.”
Happily, Smith’s dual role will be over quite soon, and Ellie is eagerly looking forward to the end of her chemotherapy treatments, which will be marked by a Make-a-Wish trip to Disneyland and Universal Studios.
A video interview with Windy Smith is available at WKOW.
Amanda Stuart postponed her wedding with her long-term fiancee and resigned from her job at an ER in Midland, Texas to care for COVID-19 patients in New York. Since her arrival, she has been working steady 12-hour shifts, taking an hour-long bus trip each day from her Manhattan hotel to a hospital in Coney Island. The shared experience of working on the front lines of the pandemic created a tight bond among the nurses on her bus, and as they exchanged personal details during the commute, Amanda says, “Many of them heard I had to cancel my wedding and began joking about having [my fiancee] Ronnie fly out here and just walk to Times Square to get married.”
The idea of a wedding in the COVID-stricken city might have sounded like a joke at first, but perhaps a life-affirming act like marriage could be a welcome counter to the stress and emotional turmoil of the pandemic. When Amanda’s fiancee decided to visit her in New York, the joking notion gave birth to a plan: “I felt deep inside me not only did I want to get married but I felt all the frontline heroes needed something positive to look forward to at this point in our journey,” and a widespread group agreed.
As in a Cinderella story for the COVID-19 era, aid came from all sorts of unexpected sources. The Times Square stairs, normally prohibited for private use—and now denuded of the usual crowd of tourists—was made available for the ceremony. There were also mysterious gifts that appeared as if by magic: “I had complete strangers provide a cake, a wedding dress, shoes, jewelry, music, and flowers for my wedding, [and] the NYPD & FDNY blocked off the ‘red stairs’ where the wedding would be held,” Amanda relates.
The festivities were a combination of the fanciful and the practical. “They made me a wedding dress out of PPE, lingerie out of scrubs, and my leg garter for my something borrowed. Something new and something blue [were made] out of a piece of scrubs detailed with a one of a kind Coney Island face patch from the Coney Island fire department crew.” Masked fire-fighters, NYPD members, nurses, friends, and family looked on as the couple (also wearing masks) exchanged vows, and nurses and other front line workers practiced social distancing as they danced in the streets following the wedding.
The bride will always treasure that special night. “We realized how much we ALL needed that moment… My dream come true was something I never, ever could have imagined! A small town girl from Arkansas with the wedding of a lifetime!”
For the full story on Amanda’s NYC wedding, see the story on WBTV.