To cope with diminishing resources during the state’s spike in COVID cases, the South Carolina Department of Health and Environmental Control and the State Board of Nursing have issued a temporary order permitting graduate nurses to treat patients during the crisis.
At Medical University of South Carolina’s Florence Medical Center, Chief Nursing Officer Costa Cockfield stated, “This is a win-win situation, the nursing students have a pathway to work while waiting to take the licensure exam. Likewise, the hospital benefits by getting the new graduate oriented and into clinical practice much faster.”
With NCLEX testing sites closed due to the pandemic, the state has been suffering from critical nursing shortages that have been unrelieved by any inflow of new RNs. Under the new order, graduate nurses who have not been able to take the NCLEX can temporarily fill staffing gaps despite lacking a license. The new rules apply to graduate nurses who have registered for the NCLEX and have graduated from an accredited nursing program. The grads are required to work under the supervision of an RN at all times.
Tony Derrick, Chief Nursing Officer at McLeod Medical Center, said, “There is certainly a place where… [these graduate nurses] could fit in to assist as a resource, and while they’re doing that, they’re learning, so I think it’s a positive win for both the student nurse for resource allocation as this pandemic continues and I don’t think it hurts to have this as a good resource.”
South Carolina is one of the few states to issue an order to temporarily admit graduate nurses into the workforce. In March, Ohio governor Mike DeWine signed a bill allowing newly graduated nurses to obtain a temporary license prior to passing the NCLEX, but so far few states have followed suit. Prior to the state’s surge in COVID cases, the Texas Nurses Association, the Texas Board of Nursing, and the Texas Organization for Nursing Leadership issued a joint statement advising that “Prelicensure RN students from diploma, associate degree and baccalaureate degree nursing programs and PN/VN students from certificate nursing programs could augment and support nursing services in health care facilities.” The American Organization for Nursing Leadership released a policy brief recommending similar measures, but such proposals have not gained traction among officials and legislators.
For more details on the decision in South Carolina, see the story at the Florence, SC CBS affiliate site.
We’ve all been experienced it: maybe new graduates are experiencing it right now…it’s the first day on the job with our freshly minted nursing degree and “what in the world am I doing here?!” is running through your head. Despite studying diligently to pass those exams, surviving the NCLEX, and making it through on-the-job training, Imposter Syndrome still hits close to home for many graduates. We’ll be discussing what it is, who is affected by it, and how to overcome it.
What is Imposter Syndrome?
Let’s not confuse imposter syndrome with new nurse jitters. New nurses may feel unsure of themselves and their knowledge especially during the first year on the job. However, Imposter syndrome is a constant, relentless feeling of never being good enough or that one is a “fake” at his or her job or responsibilities. In Patricia Benner’s classic book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, she compared being a novice nurse to learning a new skill like learning a new language: “in the beginning, performance is halting and rigid, and one must pay attention to explicit instruction. Performance is rule governed.” Imposter Syndrome is more of a feeling or a mindset than an action.
Who Experiences It?
Not just nurses experience this phenomenon. People from all ages and industries can feel the pangs of Imposter Syndrome. It seems to be experienced when someone is new to a role or has taken on different responsibilities. Therefore, it would make sense that new nurse graduates could have thoughts or feelings of being an imposter. “The syndrome is most common among women leaders who feel they don’t deserve the success they’ve achieved despite external evidence of their competence,” according to researcher Rose Sherman. It’s also likely to be experienced by people who describe themselves as perfectionists. Other people who are prone to this syndrome are those who have a competitive nature or those working in high stress environments.
How to Overcome It
John Discala lists six ways to overcome this mindset. It can be helpful to try a variety of strategies to shift away from this mode of thinking. Two ways are staying positive or talking with a friend. Dr. Lowinger coaches health professionals and in her 2019 article for Hospital and Healthcare, discusses other tips for managing Imposter Syndrome. She notes building confidence is key. How does someone build confidence? Taking an honest look at strengths and weaknesses and being realistic. Is what ever the nurse is feeling really the truth in the scenario? It’s important for the person to be honest with herself. Lowinger includes tips for both individuals and leaders for building confidence. Once someone is feeling surer, other negative feelings of inadequacy may dwindle and reality may be clearer to see.
Why Is It Important to Help Nurse Graduates?
“[Imposter Syndrome] has important implications for individual health professionals and the system as a whole,” says Lowinger. As a nursing profession, we should be mindful that new nurses commonly feel Imposter Syndrome. It’s important that nurse educators and programs in nursing schools teach about this. It would be interesting if more studies existed that investigated new nurses leaving the profession due to Imposter Syndrome. Could they truly be leaving because of this mindset? Could this mindset be so strong and detrimental? More research is needed. The nursing workforce cannot afford to lose more capable future nurses from this way of thinking that is treatable.
Imposter Syndrome is a persistent feeling or state of mind that the person is not good enough or a “fraud” in his or her job. Many people, despite industry, experience these feelings and particularly so if they are new to a role. People with specific personality traits such as high achievers or perfectionists tend to experience Imposter Syndrome more. There are several strategies available to minimize these feelings and there is much data showing this syndrome is common. It’s important to address this in nurse graduates because the nursing profession has the potential to retain more nurses who could otherwise leave due to Imposter Syndrome. Nurse graduates should be reassured that this phenomenon is felt by many and utilizing the strategies can help. A final suggestion is if the strategies in this article aren’t helping, to consider seeking professional help from a counselor or coach.
Students at the University of California Irvine Gross School of Nursing made good use of their downtime by paying virtual visits to non-COVID patients at the UCI Medical Center. Between May 4 and their June 13 commencement, 45 iPad-wielding undergrads and graduates took part in the UCI Health Virtual Visitor Project, working in pairs to make bedside Zoom visits.
Virtual visits from sympathetic nursing students brought real-life comfort to isolated patients. One non-COVID patient, Cristian Lopez, was being treated for injuries in a devastating motorcycle accident. Facing the prospect of a year of recovery and physical therapy after five surgeries, he was feeling alone and vulnerable when the Virtual Visitors reached out: “I got a little emotional because I’m still undergoing a lot of trauma, but they made me feel that I had good energy, that I’m on the right path. They were very kind. They just allowed me to talk, which made me feel good.… There’s something special about this place. They really take care of people.” He was deeply moved by his visitors. “I don’t remember anything about the accident. But I’ll always remember them.”
The emotional response of Lopez was not unique, according to Daniel Bernstein, nursing manager in UCI Medical Center’s orthopedics unit: “I had a spinal surgery patient tell me after a session, ‘That was the highlight of my day.’ Then he started crying. The value of the service is that it makes patients feel better and makes [nursing students] feel as if they’re doing something important.”
The students were quick to appreciate the value of the project. In their virtual visits, they were able to connect with abilities at the very heart of the nursing profession. Student Araceli Melchor Cruz reflected: “This project reinforced how important it is to have good communication with our patients, to listen to them and to provide care not only physically but also emotionally. Personally, it was very rewarding to know that even though we were not actually at the hospital, we were able to do something for the patients.” Sahra Kakwani, another Virtual Visitor, added, “In our nursing program, one thing that we learned can be very useful for both the nurses and the patients is to talk to them about anything. I think this program had so many positive results, especially in preventing patients from feeling socially isolated.”
For the full story on the UCI Health Virtual Visitor Project, click here.
To help meet the growing demand for RNs, Iona College in New York is about to join the ranks of schools offering a BSN program. This fall, Iona will provide students with two routes to obtain a Bachelor of Science in Nursing degree: one option is to embark on a traditional 4-year undergraduate program with a core liberal arts curriculum, while students who already have a bachelor’s degree in another field will be able to take an accelerated, 15-month second-degree program.
In announcing the launch of the new program, Iona College president Seamus Carey remarked, “As we have seen throughout the COVID-19 pandemic, nurses truly are heroes – and the world needs more of them. In keeping with the mission and values of an Iona education, the nursing curriculum will prepare nurses who can both initiate and adapt to change, serve patients with compassion while demonstrating critical thinking in health care innovation, engage in bold leadership and advocacy, and seek knowledge wherever it presents itself in pursuit of a global culture of health.”
Darrell P. Wheeler, Iona’s provost and senior vice president for Academic Affairs added, “Iona College is committed to and well positioned to offer a cutting-edge, interdisciplinary nursing program that will prepare students to meet the challenges of health care delivery and leadership in today’s and tomorrow’s complex health care system. Being in New Rochelle, just five miles outside of New York City in Westchester County, our students will have hands-on experience in some of the nation’s top facilities. We cannot wait to welcome our first class of exceptional students this fall.”
Located some 20 miles north of Midtown Manhattan, Iona College is a Catholic, coeducational institution with a total enrollment of about 4,000 students. The new BSN program, under the direction of Susan Apold, Ph.D., RN, ANP-BC, GNP, FAAN, FAANP, is designed to take advantage of the school’s proximity to New York City and will provide students with clinical opportunities at leading hospitals in the Metropolitan area. For full details on the new program, visit the Iona College BSN page.
Nurses in every clinical practice specialty will encounter a patient who is dying and will provide care to that patient as well as give support to the patient’s family. This is not a new phenomenon and the experiences of nurses providing end-of-life care have been extensively documented (Coffey, et al., 2016; Holms, Milligan, and Kidd, 2014; Hussin, et al., 2018; Lusignani, et al., 2017; Puente-Fernandez, et al., 2020; Zheng, Lee and Bloomer, 2018). Over the last several decades, nurses continue to report a lack of education and preparation to manage the complex care associated with dying and decision making at the end of life (Holms, et. al, 2014; McCourt, et. al, 2013; Suryani, et. al, 2018). Nurses’ experiences with death and dying under “normal” circumstances can be challenging and emotional as they advocate for patients’ wishes and promote a comfortable, dignified death (Griffiths, 2019; Peterson, et al., 2010).
Enter COVID-19 – a coronavirus that affected the globe and caused healthcare workers, including nurses, to change their routine practice of caring for patients, particularly dying patients. There is no current literature on the effects of this global pandemic on nurses caring for this special population of dying patients. Pattison (2020) reviewed some literature on disaster management and end-of-life care with outbreaks such as the H1N1 virus; palliative and end-of-life care planning is not fully developed and still needed. In this current pandemic, COVID-19 has caused a high number of unexpected deaths, there has been greater demand for beds and other resources, and provision of end-of-life care has been hampered due to respiratory transmission of the virus and maintaining safety for nurses at the bedside.
Nursing students, often employed in hospitals as patient care technicians, are witnessing death and dying at an alarming rate. As a professor at a local university, I have spoken with third and fourth-year nursing students who were working in hospital units designated for COVID-19 patients. The students shared that they were performing multiple post-mortem cares on patients that had died from the virus. Students also discussed the difficulty of trying to manage communication between the dying patient and their family, since visitors were restricted. Technology such as smart phones or tablets were used to have video conversations between patients and families as the patient was nearing the end of life.
It is imperative that nurse educators in both academia and healthcare systems provide additional and continuing education and support to nursing students as well as nurses practicing at the bedsides of the dying. The high stress environment of a COVID-19 unit paired with critically ill patients who may die unexpectedly may cause burnout in nurses. Resources such as the End of Life Nursing Education Consortium (ELNEC) are available online for educators to share with students and nurses. ELNEC has provided educational resources for palliative care and end-of-life care to nurses for the last two decades. Information in the modules includes physical symptom management, pain, spiritual care, ethical/legal issues and communication. ELNEC has created free online resources in response to COVID-19 and may be useful for pre-licensure education as well as continuing education and support for nurses (ELNEC, 2020).
Further support which can be provided to students and nurses includes virtual support groups, arranged by nursing faculty, hospital nurse educators or referral to social media support groups. When nurses are ready to talk about their experiences with dying patients, they need an outlet to express their emotions regarding their participation in end-of-life care during a pandemic. This may assist in validating their feelings and sharing their grief. Additional strategies to enhance positive coping mechanisms include self-care such as exercise, sleep, healthy diet, leisure activities, and spiritual or religious support (Zheng, Lee and Bloomer, 2017).
COVID-19 has changed the way nurses interact with patients and families at the end of life. Technology has been a useful tool; however, we must not forget the human side of care. The need for pre-licensure and continuing education on end-of-life care is essential. Nurses have been reporting high anxiety and lack of preparedness about caring for a dying patient over the last several decades. We must provide education as well as emotional support to our front line during this pandemic as well as prepare for future pandemics and other unusual circumstances surrounding the end of life.
Coffey, A., McCarthy, G., Weathers, E., Friedman, M., Gallo, K., Ehrenfeld, M., Chan, S., Li, W., Poletti, P., Anotti, R., Molloy, D., McGlade, C., Fitzpatrick, J. & Itzhaki, M. (2016). Nurses’ knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five counties. International Journal of Nursing Practice, 22, 247-257. DOI: 10.1111/ijn.12417
ELNEC (2020). End of life nursing education consortium. https://www.aacnnursing.org/elnec
Griffiths, I. (2019). What are the challenges for nurses when providing end-of-life care in intensive care units? British Journal of Nursing, 28, (16), 1047-1052.
Holms, N., Milligan, S. & Kydd, A. (2014). A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. International Journal of Palliative Nursing, 20, (11), 549-556.
Hussin, E., Wong, L., Chong, M. & Subramanian, P. (2018). Nurses’ perceptions of barriers and facilitators and their associations with the quality of end-of-life care. Journal of Clinical Nursing, 27, (3-4), e688-e702.
Lusignani, M., Gianni, M., Re, L. & Buffon (2017). Moral distress among nurses in medical, surgical and intensive-care units. Journal of Nursing Management, 25, 477-485. DOI: 10.1111/jonm.12431
McCourt, R., Power, J. & Glackin, M. (2013). General nurses’ experiences of end-of-life care in the acute hospital setting: A literature review. International Journal of Palliative Nursing, 19, (10), 510-516.
Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus (COVID19) pandemic. Intensive & Critical Care Nursing, 58. DOI:10.1016/j.jccn.2020.102862
Peterson, J., Johnson, M., Halvorsen, B., Apmann, L., Chang, P-C, Kershek, S., Scherr, C., Ogi, M. & Pincon, D. (2010). What is so stressful about caring for a dying patient? A qualitative study of nurses’ experiences. International Journal of Palliative Nursing, 16, (4), 181-187.
Puente-Fernandez, D., Lozano-Romero, M., Montoya-Juarez, R., Marti-Garcia, C., Campos Calderon, C., & Hueso-Montoro, C. (2020). Nursing professionals’ attitudes, strategies, and care practices towards death: A systematic review of qualitative studies. Journal of Nursing Scholarship, 52, (3), 301-310.
Suryani, R., Allenidekania, A. & Rachmawati, I. (2018). Phenomenology on nurses’ experiences in understanding the comfort of children at the end-of-life. Indian Journal of Palliative Care, 24, (2), 162-166.
Zheng, R., Lee, S. & Bloomer, M. (2018). How nurses cope with patient death: A systematic review and qualitative meta-synthesis. Journal of Clinical Nursing, 27, e39-e49. DOI: 10.1111/jocn.13975
School may be closed, but nursing students have continued to learn while working on the COVID-19 frontlines. Most find that they are more dedicated than ever in the wake of the pandemic. Now in her third year at University of Virginia, Martha Peterson says, “It’s definitely made me want to become a nurse even more. All this has also given me a greater appreciation of nursing, too. If it’s for the greater good, and helps people survive, the risks are really worth it.” “I do think that I feel more needed than ever, more necessary,” says fourth-year UVA student, Tyler Gaedecke, who begins work on a pediatric ICU this month.
A major challenge for many has been learning to cope with fear. Gaedecke says, “There are some who’re asking, ‘Did we sign up for this?’ which will be a big debate for years in the particular generation of nurses I’m a part of, and that’s a complicated question, but I’m definitely ready to get out there.” Northeastern University grad Hannah Terry made herself available to work wherever she was needed at Massachusetts General Hospital, but she admits to having been deeply afraid: “Seeing that some of these patients were so young and there was nothing [else] wrong with them—this was at the time where everyone was saying that it was only the elderly and the immuno-compromised that were getting sick. A lot of people were—including myself—very fearful of what we couldn’t see.”
Third year Northeastern student Susan Dawson, reflecting on her 36 hours a week on the COVID-19 ICU at Massachusetts General, said, “I’m glad I had hospital experience before this all broke out. I think I would have been a lot more scared and tentative if I had not.” However, she cannot help feeling emotional when she thinks about the death toll. At the height of the outbreak, Dawson recalls, “The patients are not just in-and-out in a few days. We see these patients each day, we get attached to these patients, even though they can’t talk—we still are attached to them, we care for them. Seeing a patient not come out of this, knowing that the doctors and nurses are doing everything they can, it just isn’t good.”
Overall, though, students have focused on giving patients the best nursing care possible under such extreme conditions, helping facilitate Zoom meet-ups with family members and providing human contact amid the PPE. Columbia student Ashlynn Lawrence held patients’ hands and did her best to lift their spirits: “I always try to tell them that underneath all the personal protective equipment, I’m smiling, and I encourage them to do the same. The comfort of a friendly face goes a long way.”