March 23: There is an important lesson to be learned from Italy, where COVID-19 has rapidly spread, placing a sophisticated health care system on the verge of collapse. Registered nurses (RNs) are suffering from exhaustion, contracting the disease, and leaving the workforce. As we bear witness to this unfolding tragedy, it is incumbent upon all U.S. nurses to take aggressive actions to protect our colleagues, our patients, and ourselves. Nurses who are ill or develop COVID-19 symptoms (fever, cough, shortness of breath) need to stay home. We can’t afford for nurses to infect other nurses. In fact, to ‘surge’ up to meet the anticipated demand for health care services due to the pandemic, still more nurses are needed. As a profession, now is the time to:
- implement crisis staffing contingency plans,
- expand the workforce as soon as possible,
- and ensure the health and safety of all nurses through stringent observation of infection prevention and control measures and access to personal protective equipment (PPE).
Crisis staffing.
Nurses should immediately make plans for surge capacity to address likely staff shortages. Facilities should consider polling nurses about their willingness to come to work; develop strategies to address the challenges that exist as barriers to coming to work (child care, pet care, transportation); and open conversations regarding the roles nurses are willing to play during the pandemic (see Table 1).
Table 1. Nurse Staffing Actions during a Pandemic (click table to expand)
Public health emergencies of international concern (PHEIC) such as the Covid-19 pandemic create unique challenges that require immediate adjustments to staffing patterns in order to provide additional protections for health care providers. While much of our focus is on limiting patient-to-nurse transmission of the virus, we need to also pivot schedules and assignments to limit nurse-to-nurse transmission.
Some considerations for staffing:
- Divide unit staff into three or four ‘cohorts’ or teams and establish a consistent staffing pattern. These nursing teams should always be scheduled to work together (e.g., Monday, Thursday, and Sunday) and should always have the same time off. Should one nurse test positive for SARS-CoV2, it may limit exposure and protect the health of nurses on the other teams.
- Whenever possible, identify one team of nurses to care for confirmed COVID-19 patients.
- Limit nurse-to-patient ratios whenever possible (e.g., 1-3 on medical units, 1-1 in intensive care settings).
- As the pandemic intensifies, if possible identify one nurse ‘superuser’ who has advanced understanding of the correct use of PPE as well as engineering and administrative controls for infection prevention and control to work on high-need units. This nurse can be a resource and counselor for other staff.
- Some nurses will be able to shift roles and others will need training or assistance to take on different patient care roles.
- Contingency staffing plans should include the potential use of senior nursing students, should the pandemic worsen. With proper screening to ensure students are healthy, senior students have a level of skill that will be helpful, and they may be valuable additions to the staffing mix. Even if they are not able to function as RNs, they can take over many of the duties of CNAs or LPNs. The extraordinary measures that nurses and nursing students have been required to take in other countries affected by COVID-19, such as China, Italy, Spain, and Iran, suggest it is time to utilize the skills of students and not exclude them.
Expanding the workforce.
Other strategies to recruit, retain, and mobilize additional nurses to expand the workforce include:
- The Medical Reserve Corps (MRC) is a group of highly skilled health care professionals who respond to disasters, emergencies and public health events. Each state has its own MRC. Nurses should go to https://mrc.hhs.gov/HomePage to find the link to their local MRC and register to volunteer.
- The National Council of State Boards of Nursing is prepared to assist U.S. nursing regulatory bodies to help verify licenses for nurses who choose to practice across state lines to care for patients in jurisdictions facing increased workloads associated with COVID-19.
- Several states have already moved to fast-track licensure for RNs and APRNs and to expand scope of practice for APRNs. For example, by executive order the governor of Tennessee has granted full practice authority to APRNs in response to the COVID-19 pandemic. It also relaxes regulations related to licensure and working with a license from another state. On March 14, Governor Abbott directed the Texas Board of Nursing to fast-track the temporary licensing of out-of-state nurses and other license types to assist in Texas’ response to COVID-19. See https://www.bon.texas.gov/FastTrackOutofStateLicensing.asp
- New York State has taken measures to create a reserve workforce of health care professionals including nurses by surveying those who are currently retired or out of the workforce for other reasons. Governor Cuomo has announced the survey in all his press briefings.
Infection prevention, control, and personal protective equipment (PPE).
All clinical settings should follow their organization’s infection prevention and control program applying the standard hierarchy of controls: https://www.aaha.org/aaha-guidelines/infection-control-configuration/infection-control-strategies/
Some nurses face an alarming lack of appropriate PPE while working with COVID-19 patients. Much is being proposed regarding the rapid increase in the vendor supply chain of PPE (masks and face shields). This is critically important, especially for rural hospitals who currently have little or no PPE. States with sustained community spread are running short on certain items.
As we move into the ‘acceleration phase’ of the pandemic, the federal government has released the Strategic National Stockpile (SNS) and made it available, activated the Defense Production Act, allowed for extended use, and relaxed regulations, and still what is being sent to the states is insufficient to meet the need. Jurisdictions are already reporting that they will run out of PPE and medical supplies in two to three weeks. Nurses are being asked to improvise—and that we know how to do—but some of the current recommended improvisations may be more harmful than helpful, e.g., bandanas.
Broader, more innovative policies for protecting nurses.
Policies to protect nurses needs to be much broader, more innovative, and more expansive. Some thoughts to consider:
- Use South Korea as a foundation for what to do to in protecting its health care providers. The South Korean government established enclosed protective’ screening booths’ so that the nurses never come into contact with patients. They look like vinyl telephone booths with protective sleeves for the nurses to take swabs and vital signs. See https://theglobalherald.com/dont-touch-south-koreas-covid-19-screening-booths/337901/
- Last year the National Academy of Medicine (NAM) published a report on the use of elastomeric respirators as an adjunct to surge during a pandemic. Elastomeric filtering facepiece respirators are used in industry every day and can be used in the setting. These masks are reusable (can be cleaned and stored) and would give more nurses immediate access to respiratory protection. See https://www.nationalacademies.org/hmd/Reports/2018/reusable-elastomeric-respirators-in-health-care.aspx
- Digital health applications and telehealth capabilities are being employed by physicians but many nursing tasks could also be accomplished using these technologies, limiting the time nurses are in contact with patients. Nursing should be aggressively advocating for the implementation of telehealth and digital resources in the clinical setting.
Let’s act decisively and proactively. Only if we protect each other can we continue to work to save lives.
Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN, 2018-19 Distinguished Nurse Scholar-in-Residence, National Academy of Medicine, Washington, D.C., professor of nursing and public health, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Tveenem1@jhu.edu
Roberta Proffit Lavin, PhD, FNP-BC, FAAN, professor of nursing, University of Tennessee Knoxville, St. Louis, Missouri. rlavin@utk.edu
Mary Pat Couig, PhD, MPH, RN, FAAN, associate professor of nursing, Carter/Fleck Endowed Professorship, University of New Mexico, Albuquerque. MCouig@salud.unm.edu
Appropriate staffing ratio’s are not just a problem during a pandemic, but rather something nurses face all the time. I am a part-time employee but due to the pandemic I am now required to be schedule for four 12 shifts a week. The two shifts above my regular shifts are considered extra’s and I will be put on call first if the census allows. This is very taxing as I am a student and a mother. It does not seem fair that the hospitals can require this of their nurses and as a nurse I am expected to oblige. In my hospital right now they are pulling and training the OR and PACU nurses to work in the ICU and expecting them to take 2 patients if we need them when our expected “peak” hits. This also does not seem like a safe practice but once again we are expected to conform. The ratio’s laid out in the article seem nice, but it doesn’t seem to be the reality of what we are seeing in the hospitals. Safe staffing ratio’s should be a top priority for everyone. My hope is that after this is all said and done their will be value added to what nurses do and that our profession will not be discounted and subject to what someone else says is safe.
The reference to the need for masks and face shields as PPE (protective of the wearer) is in stark contrast to some earlier advice from CMO’s that masks do more harm than good and are exclusively to protect patients.