During this unprecedented time when COVID-19 is affecting everyone in some way, one of the biggest worries that health care workers and lay people are focusing on is how medical centers and hospitals are keeping patients and their workers safe.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, is Chief Nurse of Health Learning, Research and Practice, Wolters Kluwer. In addition, Dabrow Woods is also a critical care nurse practitioner at a large health system in the Philadelphia area, and Adjunct Faculty for Nursing and Health Professions a private research university with its main campus in Philadelphia, PA. She took time to answer our questions about what hospitals and medical centers are doing to keep patients and health care workers safe.
What are hospitals currently doing (or should do) to keep patients and their workers safe right now?
To ensure the safety of all clinical staff and patients, many hospitals have restricted visitors entirely to prevent COVID-19 from unknowingly entering the building. This measure is also helping sustain the availability of personal protective equipment (PPE) for hospital staff, which otherwise would need to be shared with patient visitors, amid a national shortage.
Hospitals have also established screening measures for staff entering the building for their shifts. As soon as they walk-in, employees have their temperature taken and are encouraged to disclose if they are or have been experiencing any symptoms related to COVID-19—such as dry cough and fever.
Upon entry into the hospital, all staff members must then don a mask and wear it while they are in the building. When with patients, staff must properly use personal protective equipment (PPE) based on the patient’s infection control precautions. In addition, hospitals have established hotlines for staff to call if they think they have been exposed. The hotline, which is typically monitored by an infectious disease specialist, assesses whether the health care professional is at a low, medium, or high risk and determines the appropriate response measures for the hospital and for the individual employee.
How bad is the current situation right now in health care facilities?
The current situation is very serious, especially in areas with large outbreaks. New York, Massachusetts, California, and Louisiana are just a few examples of states that are reporting widespread transmission to the CDC. These areas are critical zones that are experiencing a shortage of PPE and other equipment such as ventilators, with facilities reaching capacity while trying to accommodate a growing surge in infected patients.
To address this situation, some facilities have set up triage tents outside of the property’s main entrance for screening, as well as have begun utilizing a single ventilator, in some under-supplied areas, to ventilate two patients of similar size and lung capacity. Hospitals have also begun implementing alternative staffing models, such as fast-tracking training for staff that are outside of critical care expertise, but can provide a helping hand—including many fourth-year medical students, nurses from other areas, and recently retired nurses and physicians (who have also been asked to rejoin the workforce).
It is important to note that the impact of COVID-19 and the required safety measures have also created a unique and unfortunate situation where many patients are made to die without their loved ones by their side. As health care professionals, we do our best to provide comfort, holding the hand of our patients, and making sure they are not alone at the end.
What are nurses doing to keep everyone safe? How are they coping?
To keep everyone safe, nurses are following strict safety protocols and working as a team, now more than ever. Collectively, the mentality is “Let’s do this.” We’re at war with this virus, and to effectively fight it requires putting aside emotions and working together to focus on our patients and what we can do for each patient in the moment.
To cope, we have the support of our fellow nurses and other care team members, as well as the option of utilizing employee assistance programs and social workers, who offer a great resource and comfort in times of struggle. We have also found tremendous support within our communities. Hospital staff has been so busy, and some haven’t even had the time to pack a meal or make it down to the cafeteria to eat, so when community members drop off food at the hospital entrance, it is an amazing act of generosity and one that is deeply appreciated.
What are some steps that are recommended to keep everyone safe?
The CDC issued a Comprehensive Hospital Preparedness Checklist to help hospitals assess and improve their preparedness for responding to COVID-19, but an essential step to keeping everyone safe is encouraging non-health care workers to just stay home. The best way to prevent illness and reduce the transmission of COVID-19 is to not leave your home, except to buy food and/or receive medical care.
What resources are out there that nurses can utilize in their health care facilities?
Nurses need to have the latest evidence-based clinical decision support content at their fingertips, so they are taking the proper precautions in caring for COVID-19 patients. The CDC and WHO are consistently updating contact precautions as well as droplet and airborne precautions, and hospitals should ensure that point-of-care tools and evidence-based resources are readily available for frontline clinicians.
What are some things that nurses should never be doing in these kinds of situations?
During this crisis, nurses should never neglect their own care. If they don’t care for themselves, they will not be able to care for others. While nurses often run towards adversity, it is important to stop and put on protective gear before we put ourselves in harm’s way, regardless of the situation. We are at war with this virus, and therefore we need to wear the proper protective gear when going into battle. There is never an emergency that is too great to forego PPE.
Is there any other information that is important for our readers to know about keeping patients and workers safe?
I think it is important for your readers to know that we will get through this, one patient at a time. Resilience is vital for situations like this one. If we look at what we can do for our patients, not what we can’t do for them, we can reframe our perspective to think not of the of the patients we lost, but rather the many we saved.
Yet another casualty of the COVID-19 pandemic may be the clinical training that’s so essential for America’s future nurses and doctors.
As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses — and, in some cases, medical students. The rationale is to protect both students and patients from getting sick and to reserve personal protective equipment, including masks, that may be in short supply.
But medical educators worry the students won’t get the hours of direct patient care experience required to graduate on time, slowing the pipeline of new health care professionals precisely at a time when the country may need them most.
“We are in unprecedented times,” said Dr. John Prescott, chief academic officer of the Association of American Medical Colleges. “Medical education hasn’t faced anything quite like this since the beginning of the Second World War.”
The risk that hospitals and other health care facilities fear was underscored this month when an instructor was diagnosed with COVID-19 after bringing a group of nursing students to the Kirkland, Washington, nursing home where at least 63 residents have been stricken by the illness — 29 of them fatally, as of Monday afternoon. Those students are now in self-quarantine.
On March 5, Kaiser Permanente requested that nursing schools temporarily discontinue student clinical rotations in its 21 medical centers in Northern California. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.) “We are in a dynamic situation and our highest priority is ensuring the safety of KP members, staff and students participating in clinical training,” a Kaiser Permanente executive wrote in an email to the nursing schools obtained by KHN.
Two other large hospital chains in California, Adventist Health and Dignity Health, soon followed suit.
As a result, the nursing schools at the University of California-Davis and Samuel Merritt University have had to scramble to find new clinical training opportunities for dozens of students. Some landed at the University of California-Davis’ medical center or clinics and others at Veterans Affairs hospitals.
Nursing education leaders in California appealed to the state’s Board of Registered Nursing on Thursday to ease the number of on-site clinical hours required for student nurses to graduate and allow them to learn from simulations instead.
State law requires nursing students to receive 75% of their clinical training in health care settings such as hospitals or nursing homes approved by the board; only 25% can be completed using simulations, such as computerized mannequins. The educators, in a letter to the board, requested that students be allowed to do 50% of their training through simulation.
“Many schools in California are experiencing serious clinical displacement. The effects of the lost clinical hours will be devastating to the students we serve,” more than 60 officials from community colleges and nurse training programs around the state said in the letter.
As of Monday, Board of Registered Nursing officials had not responded to a request for comment.
Even before the COVID-19 pandemic, some private nursing schools had pressed state regulators to allow more simulation training, arguing it has advanced to the point where it can be as effective as training in a hospital or clinic.
The move to cancel clinical training is the opposite of what happened during the 1918 flu pandemic, when student nurses were called to hospitals to care for patients. Some fell sick and died along with those in their care.
Most hospitals have not canceled clinical rotations for doctors-in-training, but some have, and Prescott, of the Association of American Medical Colleges, said more may do so in the coming weeks.
On Thursday, the University of Arkansas for Medical Sciences asked all its students to immediately leave their clinical rotations to prevent the spread of COVID-19. The University of North Carolina School of Medicine canceled clinical rotations for visiting students from other medical schools from March 30 to April 24.
Some teaching hospitals have banned medical students from emergency and intensive care units while allowing them elsewhere in their facilities.
For medical students in the University of California system, clinical training continues for now, but they’ve been directed to avoid contact with suspected or confirmed COVID-19 patients, as have medical students across the nation.
One Baltimore nursing student learned Friday that her psychiatric nursing rotation had been canceled for at least two weeks. She must complete more than 100 more clinical hours before graduation in May and has no idea whether her school, the University of Maryland, would be able to quickly find her a new placement.
“I understand why they did it, for the precaution and the liability,” said the 26-year-old, who asked that her name not be used to protect her future career prospects. “But I had eight shifts scheduled in those two weeks. I’m in a kind of panic mode, worried I’m not going to finish in time for graduation.”
Although Internationally Educated Nurses (IENs) are often
associated with struggles with differences in language, culture, and healthcare
systems, they may also “contribute to a more educated and stable nursing
workforce in patient care units” according to a new study published
in Nursing Economic$.
One point raised in the study was that units with internationally educated nurses tend to experience less turnover. The authors remark that “previous qualitative research has shown IENs are more inclined to stay on a unit longer.” Results also indicated that internationally educated nurses stay on their unit longer than peer US-educated nurses, and that the overall tenure of nurses on units with a higher proportion of IENs is longer than the average. In addition to reducing expenses for hiring and training new staff, the authors suggest that lower turnover rates can have a positive effect on collaboration among nurses.
Units with a higher number of Internationally Educated Nurses also included a greater proportion of staff with BSN degrees. This finding, the study authors suggest, is owing to the fact that internationally educated nurses “are more likely to have a baccalaureate degree to qualify for the U.S. nursing licensure exam (NCLEX-RN).” This is all to the good, as a higher level of education in nurses has been shown to lead to better health outcomes for patients. “Research shows that having more nurses with bachelor degrees improves patient safety, so it is possible that internationally educated nurses are contributing to improved health outcomes,” said Chenjuan Ma, PhD, an assistant professor at NYU Meyers and the study’s lead author.
The study was based on 2013 survey data
from the National Database of Nursing Quality Indicators, and analyzed
responses from 24,045 nurses (2,156 of whom were trained outside the U.S.)
working on 958 units across 160 U.S. acute care hospitals. The authors of the
study are Chenjuan Ma, Lauren Ghazal, Sophia Chou, Emerson Ea, and Allison
Squires of New York University’s Rory Meyers College of Nursing.
It’s hard to explain what we do. And so maybe, it’s hard for others to sympathize with our situations. I mean, physicians, mid-levels, and nurses in emergency departments are tied to computers in often cramped work-spaces, even as they are required to be at the bedside almost constantly for the latest emergency or (in other cases) the latest bit of pseudo-emergency drama.
If you haven’t worked there, or haven’t for a long time, it could be that this lack of understanding is what leads hospital administrations to do one of the stupidest things imaginable. What is that thing? Banning food and drink from our work-spaces.
Now, this isn’t the case in my current job. But it is the case in all too many facilities. I talk to people. I hear things. And it’s usually justified with some unholy combination of infection control, Joint Commission and public health clap-trap, coalesced and refined, then circulated as a cruel policy.
When it’s enacted, clinical staff have their water bottles taken
away. Nobody is allowed to eat where they work. Dedicated, compassionate
staff members grow tired and dehydrated and hungry. (Maybe it’s a good
thing. They often don’t have time to urinate anyway, and water just
makes that happen more often.)
Mind you, the water bottles are sometimes kept in a nearby room, or on a nearby shelf. It’s an act of kindness, I guess. And the food? Well, all you have to do is take your break and go to the cafeteria or to the break room, right?
Those who come up with these rules don’t understand that a scheduled break is a great idea … that never happens. It’s an emergency department. It isn’t (technically) a production line; however, we try to impose time restrictions and through-put metrics. It isn’t “raw material in/product out.”
It’s “sick, suffering, dying, crazy human being in” and if all goes well, “somewhat better (at least no worse) human being evaluated, stabilized, saved, calmed, admitted, transferred, and sometimes pronounced dead” out of the other end of the line.
Those Herculean efforts can take anywhere from, oh, 20 minutes to 12 hours. During which time, it’s pretty hard to leave the critical patient in the understaffed department, with the “five minute to doctor” guarantee and the limitless capacity for new tragedy rolling through the door.
That setting makes it remarkably hard for breaks or even meals to happen at all.
As such, it’s nothing short of cruel and unusual for anyone to say to the staff of a modern emergency department, “you can’t have food or drink” — especially when it’s typically uttered by people who have food and drink in their offices and at their desks. People who have lunch meetings with nice meals or who have time to walk to the cafeteria or drive off-campus. And who feel so very good about protecting the staff from their deadly water bottles.
The argument, of course, is that the clinical staff work in a “patient care area.” Even when they aren’t at the bedside but are, for instance, behind a glass wall at a desk. If this is the case, then one could argue that the entire hospital (including administrative suites) is a “patient care area.”
They are afraid we’ll catch something. That it’s unsafe for us to eat or drink where we work. Of course, this is while we positively roll around in MRSA and breathe in the fine particulate sputum of septic pneumonia patients. This is while staff clean up infectious diarrhea and wear the same scrubs all day.
This is after we intubate poor immigrants who may well have tuberculosis and start central lines on HIV patients. This is after we wrestle with meth-addicts who have hepatitis C. And this concern for our “safety” occurs in places where physical security, actual security against potential violent attack, is a geriatric joke which is often tabled until the next budget cycle.
And as for our patients? Our food and drink are no danger to them. They and their families fill the exam rooms with the aroma of fried chicken, fries, and burgers, eaten at the bedside (often by the patient with abdominal pain). Their infants drag pacifiers across floors that would make an infectious disease specialist wake from bacterial nightmares in a sweat-soaked panic. In short, our food or drink are no threat to them and no threat to us.
But the absence of food and drink? That’s a problem. Because the ED is an endless maelstrom of uncontrollable events and tragedies, of things beyond our control for which we are responsible. It is a place of physical, emotional, and spiritual exhaustion where we rise to the challenge and manage (against the odds) to do so much remarkable good by virtue of our knowledge, our training, our courage, and our compassion.
In the midst of all that, a bottle of water, a cup of coffee, a glass of Diet Coke, a Styrofoam cup of iced tea is an oasis in the desert. And that sandwich, slice of pizza, cupcake, or salad is the fuel that helps make it happen.
More than that, food and drink are among the few pleasures we have time for each shift. They serve as bridges to the end of the day, small reminders of normalcy in a place where so little is normal.
Doubtless, one day someone will take away our music so that it doesn’t hurt our ears, or offend our patients. We’ll fight that battle when it comes.
But until then, depriving staff of food and drink proximate to where they work is of no health value and strikes me as just one more way of exerting control over the people actually engaged in the hard, grinding work of saving lives.
On November 21, the US House of Representatives passed the Workplace Violence (WPV) Prevention for Health Care and Social Services Act of 2019 (the bill now moves to the Senate). Strongly supported by the Emergency Nurses Association, the bill now moves to the Senate for consideration.
In the U.S., the prevalence of workplace violence (WPV) in the healthcare industry is four times higher than in other private industries. According to surveys by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), some 70 percent of emergency department (ED) nurses have been hit or kicked while at work. Because of ease of public access, crowding, long wait times, presence of weapons, and other factors, the emergency department is a highly vulnerable area, especially where triage occurs.
ED Health Providers Literally on the “Front Lines” for WPV
The shocking statistics on WPV in emergency departments are behind ACEP and ENA’s campaign, “No Silence on ED Violence.” This joint effort aims to educate, empower and protect doctors and nurses working in emergency departments. By raising awareness of the serious WPV dangers emergency health providers face every day, and promoting action among stakeholders and policymakers, the campaign seeks to ensure a violence-free workplace for emergency nurses and physicians.
Acts of workplace violence (WPV) can cause physical and/or
psychological harm to emergency nurses. WPV can lead to job dissatisfaction,
emotional exhaustion, burnout, secondary trauma stress, PTSD, absenteeism, and
intentions to leave the job or nursing profession, all of which have potential
impacts on patient care.
Workplace Violence Affects Majority of ED Doctors and Nurses
ACEP President William Jaquis, MD, FACEP, said, “If you asked the majority of our nurses and our physicians, they have all been impacted directly by violence—as have I. It goes everywhere from verbal violence, which happens frequently, to physical violence. Ultimately, we hope that in sharing our stories we will gain insight and share resources on how to prevent future harm to our medical teams and our patients.”
The “No Silence on ED Violence” website includes a variety of workplace violence resources for emergency healthcare providers, including guidelines for safety in and around the Emergency Department, and lists of warning signs indicative of potential violent events.
Inspired by the Raise Your Hand movement—which first encouraged emergency nurses in 2018 to share their workplace violence experiences — ACEP and ENA have collaborated on this effort to minimize the frequency of attacks, protect emergency department professionals and build a new level of awareness about this crisis.
Some Tips on Staying Safe
To increase program effectiveness, it is recommended that a workplace violence prevention program include education and training; formal incident reporting procedures; and administrative, environmental and consumer risk assessment, physical design, and security components to address all types of WPV.
Trust your feelings if you feel uncomfortable
around a patient.
Don’t isolate yourself.
Have security around.
Call security when you first become aware of a
Maintain safe distance.
Keep an open path for potential exit.
Present a calm, caring attitude.
Don’t match the threats.
Don’t give orders.
Acknowledge the person’s feelings.
Avoid any behavior that may be interpreted as
Limit eye contact.
Further, if you do become a victim of workplace violence, report it! Underreporting is a documented barrier to effective identification and mitigation of workplace violence. Although many nurses do report WPV incidents using both informal (e.g., telling a supervisor or colleague) and formal channels, the latter is only likely when an injury is sustained. Organizational commitment including workplace policies such as zero tolerance and the role of nursing leadership for establishing a just culture that discourages bullying and retaliation—is essential to mitigating all types and forms of WPV in emergency nursing and other healthcare environments.
Passed in the House, Now Advocate for the Bill With Your Senator
Among other features, the “Advocacy” page on StopEDViolence.org focuses on S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act. Resources include an easy form for writing your Senator to support the act. In its current form, S.851 will require health care and social service employers to develop and implement comprehensive workplace violence prevention plans. These plans must include procedures to identify and respond to the common risks that make health care settings so vulnerable to WPV incidents. In addition, the bill is designed to help ensure that employees are appropriately trained in mitigating dangerous situations. For examples of action taken in State legislatures, see this PDF.
This is the first time nursing contract negotiations are being
held since 2016, when Allina hospital nurses went on strike for health
insurance benefits. These current negotiations have been in talks, with
contracts set to expire May 31. But it appears that no deal will be happening
by then, and the MNA is planning to strike again.
Workers compensation claims increased by nearly 40 percent
between 2013 and 2014, up to 70 percent, and have remained at 65 percent or
higher since then. These numbers reported by the Minnesota Department of Labor
and Industry only count the most severe cases reported, including those where
nurses missed three or more days of work due to injury.
Talks for nurse protection have been gaining speed since a
2014 incident, where a patient attacked and injured four nurses with a metal
bar. Minnesota passed a law in 2015, making hospital staff training on
de-escalating and preventing violence mandatory.
Another nurse, Michelle Smith, is back to work in surgical recovery but still going through recovery from a concussion she got roughly two years ago. She similarly is pushing for more support in negotiations to prevent these incidents from happening.