Drug overdose deaths in the U.S. reached a grim milestone in 2020. The CDC estimates that 93,331 people died, representing the highest number of deaths recorded and a 29% increase over 2019. Opioid-involved overdose death rates rose 37% in 2020, with synthetic opioids involved in a majority of fatalities. Additionally, overdose deaths involving cocaine and methamphetamines also increased in 2020.
The COVID-19 pandemic has been a main contributor to this loss of life, but a major barrier has been and continues to be, a lack of access to treatment. Data from the Substance Abuse and Mental Health Services Administration shows that in 2019, only 1.5% of individuals aged 12 years and older received any form of substance use treatment.
Though there isn’t an evidence-based medication to treat all forms of substance use disorder (SUD), three do exist for opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. Only half of clinicians with waivers to prescribe buprenorphine, however, actually do so in practice, according to a 2019 Pew study. Other research has shown that only 50% of nursing schools in the U.S. include education related to SUDs in their curriculums, and some findings are even direr.
Kristin F. Wason, NP, who works at Boston Medical Center‘s Office-Based Addiction Treatment (OBAT) Training and Technical Assistance (TTA), has been treating patients with SUDs for 12 years and recognizes the need for more addiction education in both nursing and medical schools. This is why she and her colleagues published the Addiction Nursing Competencies in The Journal of Nursing Administration. The first of its kind, the comprehensive toolkit outlines the framework and clinical skills necessary to educate, train, and evaluate nurses in the addiction space.
Article republished courtesy of Boston Medical Center’s HealthCity. To sign up for regular updates, register here.
HealthCity recently spoke with Wason about what drove the creation of this toolkit and the steps needed to increase medication access for SUD.
HealthCity: Why are nurses so critical in the care continuum for patients with addiction?
Addiction specialist Kristin F. Wason, NP, Boston Medical Center
Kristin F. Wason, NP: Substance use disorders are chronic medical conditions that are far too often life-threatening or fatal, despite safe and effective treatment options. Additionally, data shows that due to an increased risk for developing other chronic health conditions and acute care needs, persons with substance addiction present to the medical system more often than the general public—often for reasons other than primarily seeking treatment for their use disorder.
Nurses are a diverse group of frontline workers who are often the first healthcare provider that a person with SUD encounters when they present for care. Unfortunately, there continues to be a lack of addiction education within many nursing programs, leaving many nurses unprepared to appropriately screen and care for persons with SUDs. That is what motivated our team to develop this toolkit to support both individual nurses as well as nursing managerial teams in their efforts to build and evaluate nursing addiction care.
This toolkit, called Addiction Nursing Competencies, supports a holistic approach to patient care, focusing on an individual’s strengths, motivation, and personal definition of recovery. Paired with tools such as medications for addiction treatment and harm-reduction strategies, these competencies aim to enable nurses to safely and effectively deliver care to persons across the spectrum of the substance addiction from active use to long-term recovery.
HC: We know that keeping patients with SUD engaged in care can lead to additional improvements in health outcomes. Can you please describe these benefits?
KW: By engaging persons with SUD into care and providing education about harm reduction, we could also expect improvement in commonly co-morbid health conditions, such as HIV, hepatitis C, skin and soft tissue infections, and improvement in chronic health conditions, such as hypertension, diabetes, and respiratory illnesses.
Programs, like BMC’s OBAT, that are integrated within our primary care and other health systems help promote access to a variety of resources, such as family planning services and preventative healthcare. Our nursing teams have been vital in ensuring patients are adequately immune to hepatitis A and B, in particular, by checking titers and providing vaccines during addiction treatment appointments. We are also able to help coordinate and facilitate behavioral health treatment services within our institution and community.
HC: You’ve been treating patients with substance use disorders for a majority of your nursing career. Why did you choose to go into this specialty?
KW: I grew up within a community that very much struggled, and continues to struggle, with substance use and addiction. I have always carried a strong belief and understanding that good people are impacted by addiction and deserve care.
Upon graduating, I was not familiar with the role that nurses could have in caring for persons with addiction. It always seemed like a field that was more focused on “counselors” or 12-step programs.
Within a few days of working with the BMC OBAT team, I felt at home. The way the patients opened up and shared such intimate details about their lives was fascinating. The patients encouraged me to ask questions as they clearly enjoyed teaching me, a new young nurse, about the dangers of the drugs they were using, how they were using them, and all of the work that they were doing for their recovery. Many had been to numerous detoxes, meetings, counseling, residential programs, and psychiatric facilities. They had tried it all. They shared the barriers to recovery, and there were, and continue to be, many.
Some patients also said that the best treatment was finding a program, like OBAT, that provided ongoing treatment, including medication, which allowed them to feel normal, function during the day, and live their own life within their community safely and proactively. The medication for addiction treatment and care team support provided a form of relief and freedom.
I have been fortunate to work in the field of addiction for nearly my entire nursing career and it has been incredibly rewarding to partner with patients on their journey to recovery. Some patients I met immediately post-incarceration, who are still connected to OBAT, are now employed, housed, and maintaining long-term recovery. Many of my patients have become parents over the years and now bring their kids to our visits. It’s incredible.
HC: It’s clear that stigma still plays a role in both patients with SUD accessing treatment as well as clinicians’ willingness to treat patients struggling with addiction. How will publications like this help reduce the stigma on both sides of this equation?
KW: Substance use disorders are complex, chronic medical conditions that have been historically viewed as social rather than medical problems. Persons with substance use disorders deserve empathetic, respectful, evidence-based care for their condition, and the current lack of training and knowledge by clinicians and providers is a significant barrier to accessing care.
The Addiction Nursing Competencies aims to provide nurses, who are frontline staff trained in acute and chronic disease management, with the clinical and education guidance to provide safe and effective care to persons across the spectrum of substance addiction from active, ongoing use to sustained recovery.
While progress has been made, stigma still exists related to evidence-based care, particularly centered around ongoing medication treatment and harm-reduction strategies. We have a lot of work to do in terms of educating our workforce and the public about the benefits of comprehensive addiction treatment for all patients across the spectrum of substance use and recovery.
This interview has been condensed and edited for clarity. The original version of this article can be found at the HealthCity website.
Our latest Nurse of the Week has a truly American story. A freshly graduated BSN from Herzing University-Madison, he began work in January as an ED nurse in Madison, Wisconsin. Richard Onyait was born in Uganda and worked there as an orthopedic clinician (roughly equivalent to a PA in the US). Six years ago, Richard came to be regarded as a dissident by authorities and was forced to flee the country for the safety of himself and his family. Upon his arrival in the US, he decided to become a nurse. DailyNurse spoke with Richard shortly after he took his NCLEX. To see the second part of this two-part interview, click here or use the link at the end of this post.
Richard Onyait, RN
DailyNurse: So, how did the NCLEX go?
Richard: I was issued the license this morning.
DN: Congratulations! And you have a position already as an emergency department RN?
Richard: Yeah. They were basically waiting for my license. I will be starting on Monday.
DN: With your previous experience as an HCP, I guess you sort of knew you were going to pass the NCLEX.
Richard: Yes, I believed in myself.
DN: Do you still have family in Uganda?
Richard: Yes. I actually don’t have family in the US.
DN: Have you been going back to visit since you moved here?
Richard: I haven’t seen my family in seven years. [For a summary of conditions in Uganda, see this Human Rights Watch 2020 report.]
DN: Where were you born and raised?
Richard: I grew up in a city of about a million people. [Which we are concealing to protect his family in Uganda. -ed].
I was born an only child. And then somewhere along the way at 10 years old. I lost my dad. Which was part of the inspiration that drove me to study nursing and healthcare in general.
DN: What happened to your father?
Richard: Well, when I was 10 years old, my father was involved in a motor vehicle accident and sustained multiple injuries. He was treated at the local hospital. And it was during that time when the nurses took care of him that I was inspired by the compassion, the care, the love they showed in caring for him. Eventually, he succumbed to the injuries and passed on.
But that was where my inspiration came from to enter nursing school and study healthcare. So it was a painful moment for me to lose my dad, but it was also an inspirational moment that opened my eyes to serving humanity when they are broken down by illness, disease, accident, or old age. I like to call it the time that I received my calling into service.
“It was a painful moment for me to lose my dad, but it was also an inspirational moment that opened my eyes to serving humanity when they are broken down by illness, disease, accident, or old age. I like to call it the time that I received my calling into service.”
DN: You were only 10 years old?
Richard: Yeah. That wasa hard time. Because my father was my everything. He was the breadwinner at home. My father provided for everything I needed. From clothing to eating to going to school, he was a friend of mine. So it was a hard thing for me.
DN: At that at that age, too. You lost the person who just seemed to make the world safer.
Richard: (With some emotion) Yeah, it still brings tears to me sometimes. It’s a loss.
DN: So, you experienced two major life events at the same time, and when you grew up, you worked as an orthopedic clinician in Uganda. Did you work in your hometown?
Richard: No, I ended up working in the capital city, Kampala, at the National Referral Hospital.
DN: When and why did you decide to leave and come to the US?
Richard: Well, my journey to the US wasn’t one of choice. It was one of escaping the claws of a dictatorship that is currently ravaging Uganda. I had to find another home, not by choice, but by necessity.
DN: It sounds almost inconceivable to someone who has never lived outside the US. We know that Uganda is a dangerous and repressive police state, but the reality is hard to fathom.
Richard: It’s a story that I have come to be able to verbalize, but I only share it with a few close friends I’ve made here. They’re the only ones who understand where exactly I came from and what happened to me.
But what is happening to many young men in Uganda is unthinkable, and some of them are not lucky like I was. It’s still happening. It’s not like it’s over. And, for the sake of the safety of my family, I prefer not to share too many details in public. Because my family still lives in Uganda and giving out a lot of those details would simply be too dangerous for them.
“What is happening to many young men in Uganda is unthinkable, and some of them are not lucky like I was. It’s still happening… And, for the sake of the safety of my family, I prefer not to share too many details in public.”
DN: Well, we won’t even mention the name of your hometown. But how did you end up in Wisconsin?
Richard: When I came to the US, I lived in Boston with the friend of an acquaintance who knew what had happened to me. It was the bitter cold winter of 2015. [Having come from Africa,] I remember feeling like my ears were dropping off, and the cold biting my fingers!
Then, I met a lawyer who suggested I go to the Boston Medical Center for refugee health and humanitarian rights. He recommended me and I set up an appointment. I went, and one young lady there, Jenna, even taught me how to dress for the cold. She was an amazing lady.
It took over a year and a half to get any work authorization. Oh, boy. I was craving to do something to contribute to the home that was hosting me, and I just didn’t have the means.
DN: So what was the very first job you got paid for here?
Richard: I was hired to take care of a gentleman who had MS. I got the job through a friend who was caring for that man but had to take some time off. Because he knew about my orthopedic degree, he asked if I could take over for him after I got work authorization.
Once I saved enough money, I enrolled at a small school in Framingham to get a CNA certificate. I was just trying to start. And this way I could work in an assisted living facility, which was more stable employment. So, I took the very first money I earned and paid it to the CNA school.
DN: Did you find a nursing home position?
Richard: Yes, in Framingham, a place called Valley Farm. I worked there for some time. This was also when I met the gentleman who ended up bringing me to Wisconsin.
DN: Nursing in assisted living is hard, hard work for not very much pay.
Richard: Yeah. It is hard work. I was trying to make ends meet, get a second job, so I applied to multiple agencies. One of them recommended me to this gentleman, who, unfortunately, had gotten shot in Wisconsin. He likes to say he was in the wrong place at the wrong time, but he was shot in his face and got paralyzed from the neck down.
DN: How old was he at the time?
Richard: I think he was 50 years old. And he was doing rehabilitation at Spalding. So the agency referred me to his family in Boston, and I met with them and met him as well. He needed care during the day, about 8.00 am to 4.00 pm, while his family was at work. I took care of him during those hours, drove him to his rehabilitation appointments and other appointments that he had during the day. And during that time, of course, we interacted, built a relationship, and became friends. For a few months down the road, after finishing with him at 4.00 pm, I then went to the nursing home and worked from 7.00 pm to 7.00 am.
DN: (Sigh) Nurses seem tireless!
Richard: Well, I basically was not sleeping. I left his place at four. I went home, took a shower. You know, if I took a nap for an hour, and then got ready to go to the nursing facility and work.
DN: So, why did the gentleman end up going to Wisconsin—with you in tow?
Richard: That’s where he originally lived, and he wanted to go back to be closer to his daughter. He asked if I could go with him for two months, allow him to settle in and get a new caregiver, then train the new person, come back to Boston, and move on.
I hadn’t been anywhere [in the US] except Boston, so I told myself, give it a try. You never know what you find there. But after I came to Wisconsin on my two-month contract, he wasn’t able to find another caregiver. There was no one else to care for him and he was living alone.
DN: At that point, did you decide to settle down in Wisconsin and study for your BSN?
Richard: After two months, he said, ‘Hey, I still haven’t found somebody. Can we extend this agreement for another month or so, until I can find somebody? Or would you be willing to move to Wisconsin and live here for whatever time that you can be here with me?’ I thought about it, asked a few friends, and it felt like a move that would help me gain some independence… and get some sleep!
When the man asked me to stay, I told him that I have ambitions, so I don’t think I can [be his live-in caregiver] for the entirety of my life. I have a profession I’ve always loved. And by that time, I had told him what had happened to me in Uganda, and the situation that led me to the US. So he knew I would try and push myself and start going to school so I could do more.
So, I went back to Boston, to pick up the few things I had there, and came back to Wisconsin to live with him as a home caregiver. And that’s what I’ve been doing all through nursing school, until about two weeks ago, when I moved out.
DN: Did your home-care patient finally find someone who could maybe not replace you, but take care of him?
Richard: Yes; he found a person about a month ago. Since then, we’ve been training and going over the routines with the new caregiver – you know, everything that needs to be done until they get comfortable together.
DN: When you have a talent or affinity for something like nursing, you feel the need to exercise it.
Richard: Yes. I felt like there was a lot I could offer, but I didn’t have the credentials. Even when we went to appointments—for instance, one Sunday at a hospital appointment, his suprapubic catheter got blocked. The hospital was trying to find a urologist to come and change it, scan it, and so on.
As it was a Sunday, though, we waited a long time, and they kept going around. I was there looking at him, like, ‘this is something I can basically do in less than five minutes.’ But they are trying to find somebody and it’s taking hours. And I know that he’s in distress from the retention, is feeling uncomfortable, and I can see he’s a little sweaty. So I asked them, ‘hey, do you have any catheters around?’ They said, ‘we do have cutters, but the urologist has to do it.’ I told them, “Well, this is between me and my patient. He knows I can do it, and he trusts me. Can you just get me the catheter, and everything that I need? And we’ll do it on our own in our room.’
DN: What did they say?
Richard: They refused to do it, at first, but then [my patient] demanded it. Mm-hmm. Eventually, they succumbed. And they gave me a catheter, sterile gloves. I did it, and he was good. The next day, they went in and redid everything! But at least it was okay for the day.
DN: I thought they would have screamed about insurance and things like that.
Richard: Oh, there was a lot [of screaming]. I think my patient had to sign off on some documentation.
The U.S. faces one of the most consequential public health campaigns in history right now: to vaccinate the population against COVID-19 and, especially, to get shots into the arms of people who cannot easily navigate getting vaccinated on their own.
Time is of the essence. As new, potentially more dangerous variants of this coronavirus spread to new regions, widespread vaccination is one of the most powerful and effective ways to slow, if not stop, the virus’s spread.
Mobilizing large “vaccine corps” could help to meet this urgent need.
We’re testing that concept right now at the University of Massachusetts Medical School, where I am the chancellor. So far, 500 of our students and hundreds of community members have volunteered for vaccine corps roles. Our graduate nursing and medical students, under the direction of local public health leaders, have already been vaccinating first responders and vulnerable populations, demonstrating that a vaccine corps can be a force multiplier for resource-strained departments of public health.
500 students have volunteered to join the vaccination corps. Their first project was vaccinating first responders.
Importantly, a large vaccination corps that includes local medical and public health students could help reach residents who might be missed by public campaigns and hospital outreach efforts. Students often represent their region’s races, ethnicities and backgrounds, which can make it easier for them to connect with communities that are hard to reach and might not trust vaccination.
What a vaccine corps looks like
The problem of getting people vaccinated quickly isn’t just about supply – it’s also about having enough people to carry out vaccinations, particularly in hard-to-reach communities.
If quickly mobilized on a large scale, a vaccine corps could directly meet three important challenges: accelerating the nationwide rollout of COVID-19 vaccines, ensuring that doses are distributed equitably to all and delivering on the promise that all Americans are able to benefit from major medical and public health advances.
Medical, nursing, pharmacy and other health students, as well as retired or unemployed clinicians, could deliver shots, monitor people who were just vaccinated or schedule the second doses that are required for the Pfizer and Moderna vaccines to be fully effective.
Reaching underserved communities – including their own
In particular, a large, well-organized vaccine corps could play a crucial role in reaching out to communities that are underserved, overlooked or hard to reach.
Corps members could staff phone banks to help people who lack internet or struggle to use online scheduling systems find vaccines in their areas and make appointments.
Our students in the vaccine corps have already helped administer vaccines in public housing complexes and homeless and domestic violence shelters. They could also provide transportation to vaccination sites or take doses directly to homebound elders who cannot safely venture out. In Alaska, for example, vaccine providers have been going out by plane and sled to remote villages to reach thousands of residents.
Members of a vaccination corps who share race or ethnicity with the community can also have an impact on overcoming people’s concerns about getting the vaccine. That’s important.
A poll released Feb. 10, conducted by the Associated Press and NORC Center for Public Affairs Research, found that only 57% of Black U.S. residents said they had either gotten or would definitely or probably get the COVID-19 vaccine, compared to 65% of Americans who identified as Hispanic and 68% as white. Fewer than half of Black Americans surveyed in a separate Kaiser Family Foundation poll in late January believed the needs of Black people were being taken into account.
Rural areas face similar concerns, as well as the geographical challenges of reaching people in remote areas. The Kaiser Family Foundation has found that people who live in rural areas are “among the most vaccine hesitant groups.” In mid-January, it found that 29% of rural Americans surveyed either definitely did not want to get the vaccine or said they would do so only if required.
If we extrapolate these survey results, suggesting that as many as three or four out of every 10 Americans may avoid inoculation, public health officials’ hopes of reaching herd immunity will be in jeopardy.
The potential for scaling up
The U.S. has a long history of creating health corps. After the Sept. 11 attacks, the federal government launched the volunteer Medical Reserve Corps to mobilize current and former medical professionals and others with needed health skills during emergencies. Several Medical Reserve Corps units around the country are now assisting vaccination efforts.
This concept could be expanded, including by partnering with universities, to have wider, game-changing reach. The model of service our students are testing opens up many possibilities, limited only by a lack of will and imagination.
In Texas, Pennsylvania, Tennessee, and many other states, nursing students are saying, “Would you please roll up your sleeve?”
U Tennessee nursing students prepare Covid-19 vaccine doses.
Being a nursing student during a pandemic may be lacking in some respects, but at schools of nursing around the United States, students are helping to save lives and play an historic role. Some are keenly aware of their position. In Philadelphia, PA, Alondra Torregrossa, a nursing junior at Temple University’s College of Public Health, helped vaccinate 250 health workers at the Temple U Hospital as members of the media looked on. She said, “To be there as a student nurse felt like being a part of history,” but added, with a nurse’s passion for accuracy, that “I wasn’t too nervous, because I had a recently done flu shot clinic on the Health Sciences Campus.”
At Temple’s nursing program—like many others—students leapt at the chance to take part and gain more in-person experience with patients. Undergrad program director Joelle Hargraves remarked, “The opportunity for nursing students to participate was priceless. They eagerly volunteered to be part of an interprofessional team and witnessed how nurse leaders formulated and implemented a seamless plan for immunizing essential health care providers.”
“Despite the hospital being inundated with COVID-19 cases, the vaccination clinic is a glimmer of hope.”
The University of Connecticut School of Nursing called upon their students as well, and during the first two weeks of January they administered jabs to UConn Health staff and monitored them for adverse reactions. 20 students pitched in, but Dean Deborah Chyun said, “We initially had 85 undergraduate and graduate students express interest in volunteering, as well as a handful of faculty. Due to scheduling, not all were able to participate, but that level of caring speaks volumes about our students.”
In normal conditions, students rarely provide vaccinations even during clinicals, but Covid jab duty is now offers a precious opportunity to practice nursing. For example, “There was one occasion where an individual felt dizzy post-vaccination and required further evaluation,” says Amanda Moreau, a clinical coordinator and instructor with the U Conn School of Nursing. “The student played a crucial role in identifying that the individual did not feel well and initiated the proper protocol to call for additional medical assistance…”
After helping give shots to 200 U Connecticut Health workers, needle-wielding student Rebekah Gerber reflected, “It was easy to get lost in the procedure in the moment, but as I reflect back, I realize that these vaccines will save so many lives. It is an honor to have played a very small role in distributing the vaccines.”
Nursing students at University of Tennessee administered 400 shots in a single day. “They had the chance to talk with patients, answer questions they might have about the vaccine itself or side-effects, and even deal with some folks who might be nervous about getting the injection,” according to Victoria Niederhauser, the UT College of Nursing Dean.
A U Conn nursing student remarked on the experience, “I was often asked to take pictures of individuals receiving their vaccines so they could document their participation in this historic experience and encourage others to receive their vaccines as well. Overall, the environment was positive and uplifting. Despite the hospital being inundated with COVID-19 cases, the vaccination clinic is a glimmer of hope.”
American nurses are becoming iconic images of hope as they receive the first SARS-CoV-2 vaccinations approved for emergency use. A gathering of reporters, officials, and healthcare providers applauded when they witnessed the first vaccination in Oklahoma, as Erica Arrocha, RN administered the state’s first Covid-19 vaccination to a colleague, RN Hanna White, at Integris Baptist Medical Center. White told reporters, “Hopefully this is the start of something better.”
ICU nurse and NP Helen Cordova was the first Californian to get a Covid shot.
New York ICU nurse Sandra Lindsay, the first US healthcare worker to receive a shot, told journalists, “I trust the science,” as her vaccination was recorded and livestreamed to millions of viewers.
The first in line for vaccination in Minnesota was Minneapolis frontline VA nurse Thera Witte, who declared, “I’m feeling hopeful that this is the beginning of the end” of the deadly pandemic that has so far taken over 377,000 lives in the US and 1.65 million lives worldwide.
Why I love my job @The_BMC ! Teams of people working to safely and equitably distribute vaccines to their front line colleagues getting cheered on by their friends celebrating the arrival of the vaccines! A great day, a great place. ❤️ pic.twitter.com/XfrIthFIY5
There were even impromptu parties. When the first shipment of the Pfizer BioNTech vaccine arrived in Boston, there was dancing in the streets (or the hospital parking lot)—on a chilly Massachusetts day in December-—that immediately went viral.
The first Californian to be vaccinated had initially been dubious. ICU nurse and NP Helen Cordova at Kaiser Permanente Los Angeles Medical Center changed her mind, but she still understands the mistrust. Her training, though, prompted her to research the science behind the new vaccines: “That’s probably the best thing to do, educate ourselves, get the information ourselves,” she told ABC7 in LA. “As I started to dig in a little more, I felt more at ease. I started changing my stance on it. I went from ‘absolutely not’ to ‘sure, here’s my arm, let’s do it!’”
“It’s important not just for me, but for all of those that I love.” In New Jersey, the first to roll up her sleeve was Maritza Beniquez, an emergency department nurse at University Hospital in Newark. As state governor Phil Murphy looked on with journalists and healthcare workers, Beniquez was exuberant after receiving the state’s first SARS-2 shot on her birthday: “I couldn’t wait for this moment to hit New Jersey. I couldn’t wait for it to hit the U.S!”
And as humans cannot resist an opportunity to thrill one another with foreboding rumors of sinister events, false social media posts started to appear almost as soon as states began to vaccinate healthcare workers. So, if patients, friends, or family cite the nonexistent “42-y/o nurse in Alabama found dead 8-10 hours” later from anaphylactic shock, well, what did you expect? Share a real social media event like the Boston MC flash mob, and tell them you’re keeping your mask on even after your second vaccination, as epidemiologists say we will probably have to wait until mid-late 2021 to gauge the efficacy of the vaccines.
Boston Medical Center workers went all out to celebrate the arrival of the vaccine.
For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies, and other surgeries.
That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”
Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.
Acting as “Emotional Surrogates” for Absent Loved Ones
Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.
“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”
A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.
Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.
Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”
In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.
“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”
Sense of Powerlessness
Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.
Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.
“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”
During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.
At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.
“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”
When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”
Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.
As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”
Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”
Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.
Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”
Building Resiliency
As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.
The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.
Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.
“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”
When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.
“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”
Republished courtesy of Kaiser Health News.KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.The original article can be found here.
