Nurse researcher and educator Kasey Jordan, RN, PhD knows the stereotypical image of a school nurse – overworked, underpaid and, over the past two years, often on the front lines of controversial COVID policies.
And while those things are true, they aren’t the complete picture, says this Nurse of the Week.
“We don’t always present them as these strong, capable expert professionals that they are,” she said.
The same could be said for nursing in general – or for any traditionally “female” job. But Jordan sees the power in the interpersonal connections that nurses build with their patients and, from that, their capacity to create community change.
“If we’re serious about having better patient outcomes for society, then it’s areas in which the traditional nursing role can lead that really, I think, have a lot of potential to make a big difference. Things from communication to health promotion to what happens outside of that time when people are sick,” she said.
School nurses as “change-makers”
The possibilities inherent in nursing have inspired Jordan ever since she accidentally ended up in a nursing class in high school in rural Georgia.
“In high school, there were vocational classes that we took with all the other classes, and I wanted home ec, but I got stuck in health occupations against my will. Well, it stuck, and it really resonated with me,” Jordan said. “I ended up including those classes as part of my program of study, and I did an apprenticeship program with a local family practice and just never looked back.”
Even with the limited work that a high school apprentice could take on, she felt a meaningful engagement with patients and saw the role that the nurses played in their patients’ health journeys.
Jordan went on to study nursing with the expectation that she would be a bedside nurse, but by the time she finished her program, she knew she wanted to be in public health. Her first nursing job was in the cardiothoracic unit at Duke University Hospital to gain experience. Then she worked at the health department for a time before taking a job in the emergency department so she could complete an internship while earning her master’s degree.
Through the public health department, she spent a year and a half as a school nurse in Durham, North Carolina, at five alternative schools, each geared toward a different student population that needed extra attention.
“Every school had its own flavor,” she recalled.
Yet she also started to see constraints in the system.
One small example: The alternative schools were well-connected to mental health and behavioral resources for the students. But Jordan saw that some students weren’t having truly basic needs met, like good nutrition, decent sleep and adequate physical movement. Jordan approached an administrator about this, and the answer was, “Well, there’s no grant funding for that.”
“It was like, there’s all these high-level treatments that are so valuable. But then there’s also these basic processes that are so impactful on our outcomes. And it was sometimes harder to work on those things,” she said.
In both public health and school nursing, Jordan found herself surrounded by “incredibly smart people with great ideas” who faced numerous obstacles in bringing those ideas to fruition.
“That core challenge is really what led me to go back for my Ph.D. and what, in different ways, I’ve tried to explore since then,” she said.
Now an assistant professor in the College of Nursing at MUSC, Jordan focuses on innovation management. She especially values how school nurses and other health care providers find ways to develop resilience in communities and address disaster risk.
“What I’m most excited about is nurses and health professionals finding ways to make our communities more resilient to disaster. School nurses are incredible change-makers, and so are our students,” she said.
For instance, students in the accelerated Bachelor of Science in Nursing classes are learning the change-making skills that school nurses often learn, by necessity, on the job, Jordan explained.
Innovative projects the ABSN students have tackled recently included a podcast geared toward mental health challenges during the pandemic and support for educators to understand how COVID-related changes could affect student health.
School nurses play key role in community resilience
Jordan noted, too, that local disaster response requires flexibility to adapt to specific circumstances, and that’s where she’s interested in seeing who’s doing what.
“If you consider disaster response, there’s this piece of improvisation that is in it. It’s such a fascinating area, and school nurses have been on the ground improvising to meet these needs,” she said. “It’s really inspiring – and important to understand.”
“So much of responding to disaster is locally driven,” she continued. “So understanding what professionals in community spaces need is important.”
Jordan said she loves seeing school nurses who understand how comprehensive the role can be and are pushing expectations of what they’re there to do.
“One of the amazing gifts of school nursing practice, because you are outside the traditional system, is there is so much freedom and independence,” she said.
On the other hand, that requires skills that nurses don’t necessarily come equipped with. Unlike nurses in a health care setting, school nurses may need to be more entrepreneurial to “sell” innovations related to health.
“School nurses really have to build their teams and raise whatever kind of capital is needed – social or financial – to see their changes move forward,” Jordan explained.
While there’s general agreement that addressing health and physical needs will ultimately help with academic outcomes, Jordan said, the rub is the school nurses actually have to negotiate to get what’s necessary to address that health. That’s where those skills of teambuilding in a multidisciplinary environment come into play.
“There’s good evidence that school nurses are a great return on community investment, but I think there is more to tell about the community resilience they are building that is outside the traditional expectations of what school nurses have done,” she said.
In follow-up to a previous study she conducted, Jordan is currently looking at how school nurses are leading resilience-promoting change in school settings.
Since coming to South Carolina, Jordan has been working with the South Carolina Association of School Nurses to determine what subject areas need more research to help nurses in schools. That’s how she came to do an analysis of continuing education needs for school nurses, which led to her examining how school nurses are leading resilience-promoting change in school settings.
Throughout her journey, one fascinating thing that she has discovered is that innovation can come from anywhere.
“There’s not a single profile of an innovator,” she said. “It’s something that happens in all parts of an organization. But definitely there are skills we can learn to make it more effective.”
A study comparing 618 military veterans who deployed to a combat zone after Sept. 11, 2001, and 2,099 health care workers (HCWs) working during the COVID-19 pandemic found similar levels of potential moral injury (PMI), with 46.1% of veterans and 50.7% of HCWs reporting PMI.
PMI — the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code — was assessed in two categories: other-induced and self-induced. Both types were significantly associated with gender, race, enlisted versus officer status and post-battle traumatic experiences among veterans, and with age, race, working in a high COVID-19 risk setting and reported COVID-19 exposure among HCWs.
by Emily Stembridge, VUMC Reporter
PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher rates of burnout among HCWs. “Examples of PMI we saw most were individuals being expected to do things that made them feel questionable about their participation,” said Keith Meador, MD, ThM, MPH, professor of Psychiatry and Health Policy, director of the Vanderbilt Center for Biomedical Ethics and Society, and author on the Journal of General Internal Medicine report.
“In the health care context, that may look like not being able to provide the level of care one would like to provide due to the complexities of the ongoing pandemic. As a result, HCWs were vulnerable to the consequences of potential moral injury and reduced quality of mental health, similarly to what we’ve seen in post 9/11 veterans.”
Meador has worked with colleagues to identify areas for potential improvement in the mental health of HCWs. One area that shows promising results is a collaboration between chaplains and mental health providers. Much of Meador’s work has focused on equipping chaplains to be knowledgeable and aware of PMI in the health care and military settings. On the front lines of both hospitals and wars, people often begin to question their sense of self. Whether someone identifies as religious or not, they often seek out chaplains to answer questions about the crossroads between their professional identity and sense of purpose.
Together with Jason Nieuwsma, PhD, adjoint associate professor in the Practice of Integrative Chaplaincy at Vanderbilt Divinity School and associate professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, first author on the paper, Meador has established a Doctor of Ministry program at Vanderbilt which equips chaplains in evidence-based practices to be care providers for people with PMI.
“These results are a real message about just how stressful the last couple of years have been for our health care workers, and our need for mindfulness around those issues in order to best support them,” Meador said. “We’re working to transform moral suffering and cultivate even more resilience. We need to utilize all kinds of preventative and primary interventions in support of health care workers.”
National Nurses United’s (NNU) new nationwide survey of more than 2,500 registered nurses reveals significant increases in staffing issues, workplace violence, and moral distress compared to NNU’s previous survey results released on Sept. 27, 2021. Hospital RNs also reported that their hospitals are still not adequately prepared for a Covid-19 surge.
This survey is the seventh national survey of nurses during the pandemic by NNU, the nation’s largest and fastest-growing union of registered nurses.
Zenei Cortez, RN, President of National Nurses United.
“We are now more than three years into the pandemic and not only is staffing worse, but workplace violence is increasing,” said Zenei Triunfo-Cortez, RN and a president of National Nurses United. “Nurses are experiencing alarming levels of moral distress and moral injury due to the unsafe working conditions. Since our last survey in September 2021, even more nurses have reported feeling more stress and anxiety as well as feeling traumatized by their experiences caring for patients.
“In addition, many nurses reported that their hospitals do not have surge plans or enough personal protective equipment in stock to protect staff during a surge,” said Triunfo-Cortez.
“It is unconscionable that some RNs are still reusing single-use PPE and putting their health and well-being at risk.
“Despite these challenges, nurses have continued to fight for safe working conditions and patient safety and they are organizing,” said Triunfo-Cortez. “During the pandemic, nurses at Mission Hospital in Asheville, North Carolina, Maine Medical Center in Portland, Maine, and Longmont United Hospital in Longmont, Colorado, organized and voted to join affiliates of National Nurses United. We have also been strongly advocating for federal RN-to-patient ratios legislation and for the Occupational Safety and Health Administration to issue a permanent standard to protect nurses and other health care workers from Covid-19 in the workplace.”
Here are the responses from 2,575 nurses, gathered from both NNU union nurses and nonunion nurses in all 50 states plus Washington, D.C. The results cover the period Feb. 2, 2022 to March 20, 2022.
Staffing Issues
Hospital RNs reported that staffing is worse: 69 percent reported that staffing has gotten slightly or much worse recently, a 20.2 percent increase from NNU’s September 2021 survey and a 47.8 percent increase from our March 2021 survey.
More than a quarter of nurses (26.5 percent) reported being “floated” or reassigned to care for patients in a clinical care area that required new skills or was outside of their competency, up from 17.8 percent reported in September 2021. Meanwhile, 46 percent of hospital RNs reported that they did not receive any education or preparation before being floated to units outside of their expertise, up from 44.3 percent reported in Sept. 2021.
Excessive overtime and use of travel nurses:
64.5 percent of hospital nurses reported that their facilities are using excessive overtime to staff units, up from 49.3 percent, a significant increase from our September survey.
72.3 percent hospital RNs reported an increase in the use of travel nurses in the prior month.
Workplace violence on the rise
Nearly half of hospital nurses (48 percent) reported a small or significant increase in workplace violence, up from 30.6 percent in September 2021 and 21.9 percent in our March 2021 survey. This is a nearly 57 percent increase from September 2021 and a 119 percent increase from March 2021.
Alarming evidence of moral distress and mental health
Covid-19 is still having a deep impact on the mental health of hospital nurses, who continue to face moral distress and moral injury at work. There are significant increases in all of the mental health impacts reported in our September 2021 survey.
66.8 percent of hospital RNs fear they will contract Covid, a 59.4 percent increase from September.
Nearly three-quarters (74.6 percent) are afraid they will infect a family member, a 47.4 percent increase from September.
Nearly 60 percent (58.4 percent) are having more difficulty sleeping, a 66.4 percent increase from September.
83.5 percent feel stressed more often than before the pandemic, a 56.1 percent increase.
77.2 percent feel anxious more often than they did before the pandemic, a 53.2 percent increase from September.
68.7 percent feel sad or depressed more often than they did before the pandemic, a 64.6 percent increase from September.
More than half (56 percent) feel traumatized by their experiences caring for patients, a 65.7 percent increase from September.
23 percent sought treatment for a mental health condition related to caring for patients during the pandemic, a whopping 87 percent increase from September.
Personal protective equipment
Only 71.8 percent of hospital RNs reported wearing a respirator for every Covid-positive patient encounter, up from 60.8 percent in our September 2021 survey. Meanwhile, 62 percent of hospital RNs reported having to reuse single-use PPE, an unsafe practice.
Only 32 percent of hospital nurses report that their employer has sufficient PPE stock to protect staff from a rapid Covid surge. (For more on surge plans, see “Surge preparedness” section below.)
Exposure, testing, and screening
Nearly a quarter (24 percent) of hospital RNs reported that their employer notifies them of Covid exposures in a timely manner. Meanwhile, 29 percent of hospital RNs reported that nurses are informed of exposures but not in a timely fashion. Prompt notification is essential for infection control.
Access to testing is still an issue at some hospitals: 17.8 percent of RNs report that access to testing has declined since the beginning of the pandemic.
Only 56.8 percent of hospital RNs report that every patient is screened for recent exposure history to covid, down from 61.7 percent in our September survey. Screening of visitors has also gone down since our last survey: 48.6 percent of hospital nurses reported that all visitors are screened for Covid signs and symptoms at their facility, down from 52.7 percent in our September survey.
Only 23.8 percent of hospital RNs report that every visitor is screened for recent Covid exposure history at their facility, down from 38.5 percent in our September survey.
Woefully inadequate surge preparedness
Only 24 percent of hospital RNs reported that their employer has an overflow plan to place additional, trained staff to safely care for Covid patients on isolation. This is a decrease from our first Covid survey in March 2020 when 29 percent reported that there was a plan in place to isolate patients with possible novel coronavirus infection.
Previous surveys
In 2020, NNU’s four surveys covered hospitals’ lack of preparedness for Covid-19 (March); government and employers’ disregard for nurse and patient safety (May); the devastating impact of reopening too soon (July); and hospitals’ and health care employers’ lack of preparation for the fall/winter surge, despite more knowledge about the dangers of the virus and effective measures to prevent spread (November). In 2021, NNU’s March 2021 survey highlighted the continuing disregard of hospitals and health care employers for the safety of nurses and health care workers. The September 2021 survey revealed that employers must do more to be fully compliant with the Occupational Safety and Health Administration emergency temporary standard to protect nurses and other health care workers.
After a winter of bleak news and fearful statistics about COVID, recent signs point to long-awaited relief from the pandemic. COVID cases, deaths and hospitalization are all tumbling, the CDC has issued relaxed mask guidelines, and states are lessening or ending mask mandates.
With these developments as a backdrop, nursing may finally be entering a transition, from pandemic to “endemic.” The CDC defines endemic as “the constant presence of an agent or health condition within a given geographic area or population; can also refer to the usual prevalence of an agent or condition.”
Dr. Donna M. Nickitas, dean of the Rutgers School of Nursing–Camden.
So as the country learns to live with COVID as an endemic, what are the ways that nursing should respond?
For one thing, as the profession pivots to working from an endemic stance, nursing should take time to reflect on the experience, says Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FNAP, FAAN, dean of the Rutgers School of Nursing–Camden (NJ). For one thing, “We all understand the importance of what good public health looks like, and how we have to listen and trust the science as well as the evidence,” she notes. “And that wasn’t always clear from the very beginning of the pandemic.”
For another, nurses can appreciate the growth in “how more expert we’ve become on the front line to manage more rapidly, assessing, testing, informing, educating, vaccinating.”
Filling a void
As to the toll the pandemic has taken on the nursing workforce, especially on nurses who have been on the front lines in hospital systems, “they sustained a significant amount of moral injury,” Nickitas says. “They have witnessed death after death and because of that, and what was required of them, they are exhausted, both mentally and emotionally. And many of them are burned out. And that is so heartbreaking, to know that my colleagues now have gone through this experience and have left or are thinking of leaving the profession.”
“When they go, remember they take with them all of that expertise, all of that knowledge, all that wisdom, that not only have they acquired during the pandemic but also they have acquired through their professional life. Those of us who are left behind are going to have to learn to fill that void,” says Nickitas.
For nurses who are leaving, and as we move from pandemic to endemic, one hope is that nurses who choose no longer to work in an acute-care setting “will find other opportunities and consider population health, community health and certainly public health,” says Nickitas. Or work as preceptors or teach as part-time lecturers in university settings “where we can take some of that expert knowledge and apply it to the next generation.”
On a sobering note, a new study from the American Nurses Foundation finds that younger nurses are struggling with the effects of the pandemic. Nearly half of nurses surveyed under age 35, according to a press release, say they have sought professional mental health support since March 2020. What’s more, of the survey respondents under age 25, 69% say they have been suffering from burnout, which is more than double than those older than 25 (30%).
Staffing ratios
Also, in moving to an endemic posture, “we have to do a better job at nurse staffing to recognize and compensate and support those nurses who have in essence given their professional lives to these institutions.”
The evidence is clear, notes Nickitas, “that patients get better care when the numbers are lower. They have less morbidity and less mortality. So let’s listen to the evidence.”
“I wouldn’t always say mandate legislation, but when it doesn’t work, we have to get people’s attention and we’re talking about safety,” says Nickitas. “We’re talking about people’s lives and patient safety is critically important. We’re talking about reducing medical errors and improving patient outcomes. And we know that we can do better when we have the appropriate nurse staffing ratios.”
Supporting education
To help address nursing shortages, government needs to support nursing education, notes Nickitas. “We’re going to need additional funding from the federal government, from the state governments — ensure that there are scholarship monies and research funds available in the pipeline.”
Luckily, she notes, enrollments are up about 5%. In April 2021, the American Association of Colleges of Nursing (AACN), released data that in programs designed to prepare new RNs at the baccalaureate level, enrollment increased by 5.6% with 251,145 students studying in those programs nationwide.
“We have to get ready for the next generation,” says Nickitas. Hospital systems need to regard nursing staff as “valuable assets that cannot be overlooked.”
I waved goodbye to my group of pediatrics clinical students during my first semester of teaching in February 2020. I was just starting to build my confidence in my teaching skills in the clinical environment. Little did I know, three weeks later the entire country would “shut down” and I would face unprecedented challenges in my roles as a bedside nurse and an adjunct faculty member at the Widener University School of Nursing.
Here we are, two years later, still facing the obstacles that the COVID-19 pandemic has created. As a novice nurse educator, I learned that there were plenty of challenges that I needed to overcome, but there were also some benefits to teaching clinicals during the height of the pandemic. “It’s a blessing and a curse,” I would tell my colleagues, family, and friends.
I returned to teaching in-person clinicals in the fall 2020 semester. The return was particularly challenging because the circumstances of the pandemic interrupted my pediatrics clinical group’s ability to apply what they learned virtually, such as a head-to-toe patient assessment, in the clinical setting. Recognizing that they had never listened to a patient’s heart or lungs before, let alone a pediatric patient, I adjusted my teaching approach to set my students up for success. I offered to let my students listen to my lungs so they could establish what normal sounded like. Afterward, I had them come with me into a patient’s room, and I demonstrated how to systematically conduct a head-to-toe assessment on a pediatric patient. I then accompanied my students to meet their patients, assisted them with completing their assessments, and addressed any questions they had. As the semester progressed, I was able to review policies and work with them through patient care procedures like a sterile central line cap change.
While the circumstances of the pandemic have been less than ideal, I used these new rules to build on my teaching techniques. Even though COVID-19 impacted students’ in-person clinical time, the return to in-person resulted in having groups of four students, as opposed to eight, which allowed me to dedicate more hands-on time with each of my students and their patients. Despite a smaller, more interactive group, the lack of post-conference due to social distancing recommendations presented additional hurdles and required that I incorporate different ways to promote my students’ critical thinking skills. Nevertheless, I was able to spend more one-on-one time talking with my students about their patients’ diagnoses, nursing interventions, and other aspects of nursing care. We also discussed how to prioritize interventions and cluster care.
Being a bedside nurse, nursing student, and nurse educator during the COVID-19 pandemic has been nothing short of a marathon (not that I ever run anyway). While this rollercoaster ride has yet to come to a halt, I have learned so many lessons about how to continue to develop myself as a nurse educator. Through patience, flexibility, and a few mistakes, I have grown into a more passionate faculty member. I truly enjoy watching my students transform each semester as they build their knowledge and confidence in patient care, and I plan to keep doing so in order to continue growing the nursing workforce.
Assistant Professors Christian Ketel, DNP’14, RN, and Carrie Plummer, PhD, MSN’05, ANP-BC, received Vanderbilt’s 2022 Martin Luther King, Jr. Award on Monday, Jan. 17, for developing and leading the VUSN/VUMC Mobile Vaccine program. The award recognizes Vanderbilt University School of Medicine, School of Nursing or Medical Center staff or faculty who emulate the principles of Dr. Martin Luther King Jr. in their work.
Ketel and Plummer were honored for their leadership of Vanderbilt’s mobile vaccine program, which launched in March 2021. The program, a joint venture between Vanderbilt University School of Nursing and Vanderbilt University Medical Center, provides COVID-19 vaccines to the uninsured and others who might not otherwise have access to the vaccine.
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14,000 doses and counting
It has focused primarily on residents in Hispanic, Somalian, Kurdish, African American, homeless and low-income communities. Since the program began, Vanderbilt volunteers have vaccinated more than 6,500 people and given approximately 14,000 doses (first, second and booster).
The mobile program provides vaccinations both through door-to-door outreach and clinics organized with community and neighborhood groups. Ketel and Plummer cite partnerships as key to success.
“Since the program began, I’ve learned about the power of partnership in helping break down barriers to health care access,” Plummer says. “The Mobile Clinic would not have been nearly as successful in its vaccination outreach efforts without the support of our diverse group of community partners and the passion of our volunteers.”
Among those community partners are the Hispanic Family Foundation, Elmahaba Center, Fannie Battle Day Care, Valor Academy Charter School, Amed Clinic, East Nashville Tomato Festival, YMCA of Middle Tennessee, and churches such as Our Lady of Guadeloupe Catholic Church, Casa de Gloria and Seventh Day Adventist Church South Nashville. The Metropolitan Development and Housing Agency and Urban Housing Solutions are key partners in reaching residential communities.
Staffing for the mobile clinics, door-to-door campaigns and outreach to homebound individuals has included faculty, staff and students from the School of Nursing, Vanderbilt School of Medicine, VUMC, Monroe Carell Children’s Hospital at Vanderbilt, Lipscomb College of Pharmacy, Vanderbilt Global Health Institute and volunteers from the Nashville and Murfreesboro communities. Undergraduate interns from Vanderbilt’s College of Arts and Science, Middle Tennessee State University and Tennessee State University have also been part of the project.
“These last few years of the pandemic have been challenging for all of us—on so many different levels. One of the things that kept me feeling hopeful was being able to engage in this on-the-ground work with my amazing co-director Dr. Christian Ketel, our pharmacy colleagues Dr. Sarah Uroza and Dr. Justin Kirby from Lipscomb University, and the rest of our volunteer crew.”
What started as two nurse practitioners’ instinctive desire to help vulnerable people during a health crisis of unprecedented magnitude has provided insight into strategies for fighting health inequity.
“Serving my community through the VUSN/VUMC Mobile Vaccine Program has shown me that equal access for all to medical care is possible. When you strip away the systematic barriers to health care and place people and communities first, you can achieve great things,” Ketel says.
Both faculty were surprised and humbled that they were nominated for the award and that others saw them as emulating King.
“Dr. King spoke of and fought against systemic inequities in the U.S.—including those embedded in our health care system. To receive the MLK Award, alongside my colleague Dr. Christian Ketel, is an honor and truly humbling,” Plummer said.
“Martin Luther King, Jr. paid the ultimate price for standing up for his values and beliefs. I am humbled to think that I have reflected even a miniscule amount of the love that he radiated with his life,” Ketel said. “I am so grateful for my co-director, Dr. Carrie Plummer. I have found a life-long friend and ally in the fight against health disparities.”
