Getting to know the critically ill patients they’re taking care of is hard enough for ICU doctors under normal circumstances. But it’s even worse during COVID-19.
Not only are there no visiting family members to give you information, “but the patients are all similar in terms of their medical issues, they’re all on a breathing machine, and many are lying on their bellies,” explained Brian Garibaldi, MD, associate professor of medicine and anesthesiology at Johns Hopkins Medicine and director of the isolation unit at Johns Hopkins Hospital in Baltimore, in a phone interview. “You might go for days without examining the front side of their body, so we’re not seeing their face. That makes establishing connections with patients a little more difficult.”
An Idea From the Chaplain
One day Garibaldi was talking to Elizabeth Tracey, a chaplain at the hospital who also is director of audio production at Johns Hopkins Medicine — someone very familiar with audio recordings. She had an idea: how about if she interviewed patients’ family members and made a recording of what they say? “I could edit it down to a few things families really want their doctors to know about their loved one,” she said. Garibaldi was immediately on board.
In a separate interview, Tracey — who also edits and appears on MedPage Today‘s TTHealthWatch podcast, said she had heard from a chaplain colleague who told her that a physician had said after an extubation of a terminal COVID-19 patient that “I realized I didn’t know anything about this person; I didn’t know if he had children, if he was married. I didn’t know anything.” So why not give the physicians and the rest of the healthcare team personal details — “Do they have a dog? Do they like to play poker? It’s all the things that make them human,” said Tracey.
Tracey said Garibaldi emphasized one thing: “The only way this is going to work is if it’s in the voice of the family member.” So Tracey began calling family members and saying, “Hey, I’m part of the team helping take care of your loved one … Under normal circumstances you’d be here in the ICU telling us your loved one’s story. The team would like to know your loved one better as a person; would you like to spend 15 to 20 minutes talking about them?”
So far, only one person has turned her down since Tracey began doing this in April, and that was because they didn’t like the sound of their recorded voice, Tracey said.
After getting the family member’s permission, she records the phone call and edits the comments down to 2 or 3 minutes; she estimated that she has completed 30 to 40 recordings so far. Currently, the recording is distributed to the medical staff by an administrator at the hospital, although she hopes to eventually get it added as a link in the patient’s electronic health record.
A Message to the Healthcare Team
Tracey also added a second component: the opportunity for the family member to send a recorded message directly to the patient. “I said, ‘if you were talking to your family member, what would you say? Talk to them directly.'”
“They say these things that are just unbelievable,” said Tracey. One mother recorded a message for her adult daughter, whose autistic child the mother was the custodian of. “She says, ‘I want you to know that everything is forgiven,'” said Tracey. “How can you have a more powerful example of love?” Those conversations also are edited down to 2 minutes and played for the patient.
The recordings for the medical staff are very helpful, said Garibaldi. “Just learning the simple things — What would they prefer to be called by if I met them in the grocery story? What hobbies do they like? What favorite music can we program on an iPad to keep them awake and stimulated during the day? Also, learning things like what that person has accomplished in their personal and professional life; it really puts things in perspective, to put their current illness in the context of where they’ve been, where they are, and where they might want to be going.”
Dale Needham, MD, professor of pulmonary and critical care medicine at Johns Hopkins, agreed. He noted that although the medical staff speaks with patients’ family members every day, “those conversations have to be efficient and focused, whereas Elizabeth has the luxury of spending more time, and distilling it into an audio file that we can listen to and understand and easily share.”
For example, Needham said, “we found out that one patient previously had worked at a Smithsonian museum, and we found out that one of our patients likes to tango. And we found out that one of our patients that we wouldn’t have expected — was a DJ” on the weekend, while he had a white-collar job at a law firm during the week.
“This can help us understand who the patient is, and as the sedation is lightened, it helps us interact with them in a more humanized way.” It’s also mutually beneficial because the families are aware that the staff knows a little about their loved one, he added.
“What a Gift She Gave Us”
Barbara Johnson, whose late sister was a COVID-19 patient at the hospital, agreed. “I thought it was an incredible opportunity, given that none of us could see my sister,” said Johnson, of Silver Spring, Maryland, who did a recording for her sister and one for the medical staff. (You can listen to the recordings in the player above; her recording for her sister Beverly is first, followed by the one for the healthcare team at 3:25.)
When she spoke with Tracey for the recording, Johnson said she was thinking about her sister, “What would I have said if I got to talk to her” the day she was intubated? “What a gift Elizabeth gave us.”
Regarding the recording for the medical staff, “I think that when you take away the family from a hospital room, it might be hard for doctors and nurses to relate to the individuals, and the fact that they wanted to was really quite powerful for me,” Johnson said. “I really wanted them to know what made her happy, and if she was there talking to them, what would she have told them? … I also wanted them to know — in case she woke up — that she was the kind of patient that would tell them what they wanted to hear. If she was not feeling well and wanted them to feel good about their job, she would say, ‘I’m doing great.’ So I wanted them to know, just read between the lines.”
Tracey has recruited several dozen additional volunteers — including chaplains and medical residents — to make the phone calls and edit the recordings. She also has expanded the service — which she calls “This Is My Story,” or TIMS — to include other patients in the hospital, since they also aren’t getting visitors during the pandemic. She said she hoped that other hospitals would adopt the practice.
Within the hospital, “there’s definitely a lot of enthusiasm from the medical units and also an enthusiastic response from pediatrics,” she said. “What parent wouldn’t want to record ‘Green Eggs and Ham’ for their kid?”
More than a dozen registered nurses at Blake Medical Center in Bradenton, Florida, protested outside the hospital Friday, the third such protest since the pandemic began, saying hospital owner HCA Healthcare won’t give them N95 masks unless they are working with known COVID-19 patients, and doesn’t tell them when their patients later test positive.
As case counts in Manatee County climb, many patients have been admitted to the 383-bed hospital for other reasons, but later turn out to have COVID-19, said Candice Cordero, a telemetry nurse who works with stroke and cardiac patients in a step-down unit.
“We’re seeing more random patients test positive, and some have symptoms, but some don’t, or some are admitted for one thing, and start having (COVID) symptoms a few days later,” she told MedPage Today.
“We’re having a problem with the hospital being transparent with their numbers, and letting staff know when they’ve been exposed.”
The hour-long protest was called by members of the Blake Medical Center’s bargaining unit of the National Nurses Organizing Committee-Florida, an affiliate of National Nurses United. NNOC said in a news release that it has filed complaints about unsafe conditions at the hospital with the Occupational Safety and Health Administration. The statement said that at least four RNs at Blake have tested positive since late May.
The union further alleged that Blake Medical Center management requires RNs who have been exposed to COVID to continue working until they have COVID symptoms, does not test all patients prior to a procedure or operation, fails to provide PPE replacements for broken masks, and threatens RNs with discipline for raising safety concerns.
Officials for Blake Medical Center eleased this statement in response to the protest:
“In the midst of a global shortage of personal protective equipment (PPE), Blake Medical Center has been doing everything in our power to protect our caregivers and patient care teams throughout the pandemic and equip them to provide safe, effective care to our patients by following or exceeding Centers for Disease Control and Prevention (CDC) protocols.
“We have provided appropriate PPE, including a universal masking policy requiring all caregivers in all areas to wear masks, including N95s, in line with CDC guidance. While we currently have adequate supplies of PPE, we continue to provide safeguards that are consistent with CDC guidelines and help ensure the protection of our colleagues, not only today, but into the future as the pandemic evolves. The NNU fails to recognize the reality all hospitals nationwide are facing, that this pandemic has strained the worldwide supply of PPE, including masks, face shields, and gowns.”
Cordero said that recently one patient “was not properly screened in the ER who should have been on a COVID unit. That potentially exposed several nurses and the other patient in that room.”
When she complained to human resources officials, she said, she “was reprimanded verbally for speaking up and was told that if I did it again, I would receive discipline.”
The hospital should be testing all of its frontline workers regularly, she said. “We’re much more at risk of being exposed while at work than many other jobs out there. We really should be screened better than we are.”
Kim Brooks, who works in an ICU step-down unit for trauma and cardiac patients, assumes all of her patients are infected with COVID-19 and because of that, she said, she has bought her own N95 masks since the hospital won’t buy them for her.
“We know some of the nurses who are on non-COVID units are getting exposed to positive patients and now [some] are getting sick because they didn’t have N95 masks,” she told MedPage Today.
At the very least, the hospital should inform frontline workers when patients ultimately test positive on our floor, “so we can take precautions with our family,” Brooks said.
“Once we find out someone is positive, we do move them to a COVID unit. But sometimes there’s been a situation where that patient has been rooming with a COVID patient, and that patient is sometimes left on our unit to see if they turn out to be positive.”
By Cheryl Clark, MedPage Today
Hundreds of registered nurses marched outside the 478-bed Riverside Community Hospital in California for eight hours Monday during the fourth day of a 10-day strike. They accuse their administrators of ordering staff reductions that have resulted in dangerously high nurse-to-patient ratios that put themselves and their patients at risk.
The nurses say they’re sometimes forced to work their 12-hour shifts without taking a break to eat, get a drink of water, or even use the bathroom.
It’s all the more troubling as COVID-19 case counts and deaths recently spiked in that Southern California county, they said.
“You have to sneak the break in, or you get to the end of the day and it dawns on you that you’re dehydrated and you haven’t been to the bathroom all day,” said Erik Andrews, RN, a rapid response team member at the hospital and vice president of the 1,200-member bargaining unit of Service Employees International Union (SEIU) Local 121RN. He said he’s held on for 10 hours without a bathroom break while wearing an airtight respiratory mask, feeling uncomfortable and dehydrated, yet without a backup if he steps away.
“Each nurse is entitled to three paid 15-minute breaks and a half an hour off the clock every day,” Andrews said. “If I could find a single member who got all those breaks every day, I would keel over from shock because it doesn’t happen. And now it’s expected and accepted; we’re just taking it … when it doesn’t need to be this way.”
“You can’t get away without a safe break,” said Monique Hernandez, RN, a Riverside Community Hospital telemetry nurse and a member of the mediation team for SEIU. “That means someone who says I’m going to watch your patients while you go and put your feet up, take your mask off, go eat something, clock out. You can’t do that legally if there’s no one that can watch for you, because if something happens, that’s on your license.”
Wearing purple shirts, several hundred strikers carried signs around the hospital block for the last four days starting at 7 a.m. Some of the signs said, “Imagine wearing N95 for 12 hours with no breaks,” “Caution, unsafe staffing ahead,” and “You call us heroes yet treat us like zeroes.”
Riverside Community Hospital: “Misguided Tactic“
In a statement, Riverside Community Hospital officials called the nurses’ job action “a misguided tactic” that “create(s) conflict and spreads misinformation” and has “everything to do with contract negotiations.” The statement said that Riverside Community has “not laid off or furloughed a single caregiver due to COVID-19 and has spent $160 million to pay workers, some of whom are receiving 70% of their pay even when there has been no work.”
But labor officials insisted their strike has nothing to do with money and nothing to do with their current contract, which doesn’t expire until September. They are not in negotiations now.
From the labor union’s view, the problem is that when Gov. Gavin Newsom (D) ordered the state to shelter in place in mid-March, and routine hospital operations like elective surgeries came to a halt, Riverside Community Hospital’s administrators took traveler nurses, per-diem and part-time personnel off the schedule and limited hours for other workers. Union representatives estimated that they are between 200 and 400 people below where they need to be.
Hospital officials failed to realize that even though the census has been low, the workload and burden of methodically taking extra precautions — for example cleaning reusable PPE equipment in short supply — turn what were once quick, routine tasks into more complicated, step-by-step procedures, Andrews said.
“When you’re dealing with a disease that presumably is aerosolized, and very contagious, you need people to slow down and think carefully,” he said. But there is no staff available to serve as a spotter, “for when you’re donning and doffing your protective equipment.” Also, COVID-19 patients are not always housed in separate parts of the hospital, complicating safety considerations further, and nursing staff don’t always know a patient’s status.
Nurses as Housekeeping Staff
Kerry Cavazos, RN, the labor union’s chapter president and a labor and delivery unit nurse, said Riverside’s owners, the Hospital Corporation of America, told many members of the housekeeping staff, who are represented by a different labor union, not to come to work. That meant the nurses have to do housekeeping work.
Women about to give birth are brought into rooms that are still dirty from the last delivery, she said. “There was no housekeeper to clean it and there is still blood on the floor, so we have to clean it up. The woman needs to get in the bed because she’s having a baby.”
She and her fellow nurses are told to strip the beds, wipe the poles and the IV, and stock the rooms. “Those were never nurses’ tasks. And it’s not beyond us to do that but we have other things (to take care of patients) that we need to do,” Cavazos said.
Cavazos echoed the concerns expressed by Andrews. “I honestly do not believe this is safe for any patient for a nurse to not have any nutrition or any fluids for 12 hours. But we do it because that’s who we are,” she said.
California’s Staffing Ratio Rules
The issue of hospital nurse staffing is an important one in California, which two decades ago passed the nation’s first set of maximum patient-to-nurse staffing ratios in acute care hospitals. For example, one med-surge unit nurse should take care of no more than five patients at a time. In a telemetry unit, the nurse-to-patient ratio can be no more than one to four.
But according to Hernandez, there has been no financial penalty against the hospital for violating the ratio unless there was documentable harm to a patient that the staffing lapse could be blamed as the direct cause. A new law took effect early this year, imposing fines of $15,000 to $30,000 on hospitals that failed to uphold ratios. Labor officials said that while that is a welcome fix, state health officials have not yet begun to enforce it due to the pandemic.
The history of the issue at Riverside Community Hospital regarding staffing ratios goes back several years, as the SEIU unit tried to get administrators to take the staffing issue more seriously. The bargaining unit got a contract amendment last year that required the hospital to pay a nurse a “monetary penalty” if he or she had been required to absorb more patients than the ratio allowed, regardless of whether the ratio lapse caused harm.
“Everyone was happy and they kept their part,” Hernandez said, until a few months ago when that monetary penalty agreement expired and, sometime in late May, hospital officials declined to renew it. Days after that, which was the weekend of June 13 and 14, Hernandez said, at least one unit at the hospital failed to meet the ratio, “and it’s happened repeatedly” since the agreement ended.
by Cheryl Clark, Contributing Writer, MedPage Today
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.
A spokeswoman for the health system, which serves 4.4 million Northern Californians, confirmed the cancellations.
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.
The University of Pennsylvania has suspended clinical rotations for some medical students, as has the University of Minnesota. SUNY Downstate College of Medicine also suspended emergency room rotations for its medical students.
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.”
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
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.