Nursing in a Pandemic - Pandemic Ethics Podcast with Nurse Beth

Nurse Beth, MSN

Pandemic Ethics Podcast episodes cover discussions of the defining ethical challenges of the Covid-19 pandemic, featuring world-renowned experts in ethics, public health, law, economics, public policy, and beyond. Hosted by Joshua Preiss, Director of Philosophy, Politics, and Economics (PPE) at Minnesota State University, Mankato, and the author of Just Work for All: The American Dream in the 21st Century (Routledge 2020). Visit pandemic-ethics.com for more information on recent and upcoming episodes.

Joshua

Welcome to the Pandemic Ethics Podcast. I'm your host Joshua Preiss, Professor of Philosophy at Minnesota State University, Mankato, and the author of Just Work for All the American Dream in the 21st Century, which is now available from Routledge. In today's podcast, we explore the challenges of providing essential work during the Pandemic. Our focus is nursing during the Pandemic.

My guest is Beth Hawkes acute care nurse and nursing development specialist and the author of numerous books on nursing including First-Year Nurse, A Guide for Nurses During the Challenging First Year of Practice. She's also the author of the popular Ask Nurse Beth Career Column at allnurses.com, an online nursing community of more than 1 million nurses, educators, and students.

Beth, it is a pleasure to welcome you to the podcast.

Beth

Thank you for having me.

Joshua

So, in your view, in your experience, what concerns do you frequently see or hear in your work? What challenges are nurses particularly facing in performing their essential work during the Pandemic?

Beth

Yes, that's a good question. It's extremely challenging right now during the Pandemic. I wish there were a stronger word than "extremely". It's nothing that any of us have ever seen, or prepared for. Nurses are stretched incredibly thin, just by the sheer number of patients, and the acuity of the patients. Patients are very, very sick. The patients that are hospitalised with COVID present in a different way, meaning they get sick very quickly; very, very sick very quickly. They may be oxygenating fine one minute, and then, within a few hours, be on a respirator. That's unusual. And we're just of course learning about how to treat them and so on, and so all of it's new. It takes more nurses.

The nurses themselves are getting sick. There's a level of intensity that we've all been feeling that's extremely fatiguing. Because of the vigilance, we have to be on guard all the time. Nurses themselves are getting sick in large numbers. Nurses are carrying workloads I've never seen -they're stretched very thin. Nurses that are typically on a Med-Surg unit with four to five patients are now caring for eight to 10, maybe even 12 patients. And that's because there just aren't nurses. That causes a lot of problems in and of itself, one of them being just moral distress. It's just really difficult to feel like you're doing a good job when you're taking care of that many patients that are that sick.

Joshua

From your previous response, I can anticipate your answer, but I want to give you an opportunity to elaborate. As the Pandemic drags on with infections on the rise and ICU is filling up, what is the morale of you and your fellow nurses. What have you seen or heard from readers?

Beth

Well, morale is really been affected, and it's so challenging right now for a lot of different reasons. One of them is just the sheer fatigue of nurses and there doesn't seem to be an end in sight. And we've all been warned that it's going to get worse, especially this month. This is from good predictive models, so we all feel like that's going to happen.

Also just seeing the suffering in the patients is really challenging. What nurses have to witness, the sheer number of deaths in such a short time.

The patients are, they're really sick, they're afraid, they're terrified. They're lonely, and suffering. As nurses, we feel much of that for them, and we can't always make it better, can't really help. So that really takes a toll, day after day after day. Nurses have families, too. We have families and loved ones and in the back of every nurse's mind across the globe, I think, is the fear that we may be the person to infect somebody that we love.

So that's constant. We always have this clock running in our minds and we're always counting down days and trying to determine how safe we are...did we get infected? Some nurses go home, strip right in their garage, leave the clothes there, go in the house, take a shower before they see one family member, just trying to take every precaution possible.

So we have patients that are very sick. Moral distress. Witnessing all that. And then nurses are being challenged in their practice in new ways because it's a new sickness. And then on top of that, we don't have enough nurses or nurses or the nurses that are working, are, overworked - working 16-hour shifts. Some of them are working 5 12 hour-shifts a week.

Joshua

I was gonna ask you about the availability. So I mean, this is sort of a leading question. I sort of know the answer, but it's has COVID-19 really generated, or exacerbated nursing shortages, whether in the, you know, globally, or in the United States, and what, if anything, can be done about that?

Beth

That's a great question. I'm sure everybody wants to work out what can be done about that. There's a finite number of nurses, and within that number, there's a finite number of highly ICU-trained nurses who are really in demand right now because of the patients that end up in ICU. And then also ED nurses the entry point in the emergency department. So it's exacerbated nursing shortages. Especially regionally. Maybe San Francisco doesn't have a shortage, hasn't had a shortage in the last few years, but it's a desirable location. But then in other areas of the country, they're hard-put to ever have enough nurses.

And then there's also a shortage of experienced nurses. You can't compare a new grad nurse with an experienced nurse. We can have an abundance of new grad nurses who are just not 100% productive for a very long time.

But at the same time we have a shortage of seasoned experienced nurses. That's what we're looking at right now. It's showing the transition-to-practice gap in nursing, we all know what that means. The new grads come, and there may be a lot of them, but it takes a long time to get them up to speed. The (educational) pipeline isn't really effective.

Hospitals have gone to hazard pay. But hazard pay is no longer an incentive. When you're completely fatigued, it doesn't really matter what the amount of money is. You're just not replenished. There's just nothing to give. It's hard to bring it. So it's very difficult.

They're relying on traveling nurses, crisis nurses, quite a bit. I work in the orientation department, I'm a Nursing Professional Development Specialist. And yesterday we had six paramedics come in that were assigned by the state. And the week before that, we had the National Guard unit show up and before that we had crisis nurses. Traveling nurses are very highly paid to come in and just work short term contracts.

Back in the beginning of Spring, I got a phone call on a Friday night saying, "Beth, can you come in on Saturday, and orient with the state. California State is sending us a group of nurses that they recruited.”

So when I got to work on Saturday I started talking to these nurses and, Oh my gosh! Two of them, there were four, and two of them had been retired for a long time; one had been a school nurse, never worked in acute care, and another one had been working somewhere in South America on a mission trip for years. And anyway, they just really weren't ready for acute care. Then I asked them, "How long are you here for?" They had a 48-hour contract! 48 hrs. 12 hrs orientation.

I wrote an article about it on allnurses,

A Day in the Life of an Educator During Covid. It's hard. It's very difficult to find the right nurses with the right training who can jump in during a Pandemic.

You can have the heart for it, and you can be called to the mission, so to speak, but that doesn't mean that you can manage patients on ventilators with this disease.

So they're really scrambling trying to get nurses and health care workers from everywhere. My job is changing in that I used to have a scheduled bi-weekly orientation when we onboard new people. And now we get nurses any day. When they find nurses, we all drop what we're doing and rush to get them to the bedside as fast as we can because it's that critical.

Joshua

I can only imagine the challenges of integrating nurses with such a diverse set of backgrounds. In terms of experience and expertise, even as everyone else is already exhausted from their efforts during the Pandemic.

You mentioned moral distress. I'd love it if you could share a bit more about that. Do you feel like nurses have a sense that they are unable to do their work according to the values that they hold central to the nursing profession?

Beth

I think the values in nursing have always included a duty to care, and nurses are very good at that. And dignity. We respect our patients, and we strive to maintain their dignity under any circumstances. Most nurses take a great deal of pride and gratification in doing that for our patients. And that hasn't changed.

But there may be a shift from another value that we have - focusing all possible resources, and we've always had lots of them, on the patient that we have - individual patients. So there could be a shift, depending on how this progresses, from patient-centered care to population-health. Meaning triaging. Meaning, rationing care, rationing resources. I think that's really difficult to wrap your head around for nurses, probably for doctors too. It's a different way of thinking, and then to be called to do that in the middle of a crisis but we may have to. Yesterday, Los Angeles County Emergency Medical Services issued a directive that the paramedics were not to give patients oxygen, because that's becoming scarce unless their O2 Sats dropped to 90, which typically the cutoff would have been 92, it's just a measure of the amount of oxygen in your blood. So that's just a clear-cut example of rationing resources.

You can read more about it here "Rationing Care: Whose life is Worth Saving?"

Joshua

That's very on point. Thanks so much for sharing that information, that background. Is there sensing, you talked about, amazing but also really challenging work that is being done here to literally keep people alive or keep people living a quality life? As you know, in a previous episode of the podcast, Joan Toronto and I talked about, care and care work, and whether or not institutionally or socially there was the kind of priority needed to be given to that work. Do you get a sense, do you and your fellow nurses get a sense that the challenges you're facing, the social importance of your work, the additional risks you're taking on during the Pandemic - Do you feel like this is being recognised by society as a whole, and how might it be better recognised both during the Pandemic, or maybe to sort of set up a situation where we're even more suited to handling a crisis in the future?

Beth

Well, are we recognised? Yes and no. I think mostly yes. I don't think nurses necessarily seek recognition. I think the public holds us in high trust and has for a long time. At the same time, I don't think people really have a good understanding of what nurses do, and there's a lot of reasons for that, probably a different podcast. But in my community, there's a lot of appreciation for healthcare workers - you know, Starbucks giving us free coffee and local restaurants sending food to the hospital to the nurses and health care workers that are on duty.

You know what's interesting is, I believe that nurses want recognition from nursing administrations, hospital administrations. I do think there's a lack of that. Nurses do not typically feel valued by hospital administrations. That's been very hard for nurses to realise, understanding the important work that we do, and understanding that our employers don't get it - the value that nurses bring.

I think it's become very clear, nurses are central right now in this Pandemic. I think they're beginning to see it's not just a matter of "how many ventilators do you have". You must have trained personnel to go with those ventilators or it's not helpful.

So when you ask about the social importance it's really kind of ironic. I do think, to the amount that the public understands what we do, and there are some misconceptions out there, that they do appreciate and recognise and trust nurses.

But inside our own profession, we sometimes feel a lack of that.

Joshua

And when I speak of social importance too, I also mean, do you feel like there's an appropriate sort of dedication of time and resources to nursing as a profession or to nurses? And I think maybe another way of asking that is, in addition to pats on the back and gifts of coffee and the like, what things could people in general do or what practices or policies might make it easier for nurses to do their job during the Pandemic or even beyond?

Beth

Again, this wouldn't really be from the public. I'm going to answer it more from a point of view of what could be done by employers, if that's okay.

To make it easier for nurses to continue to do the job, number one, they need to ask nurses for their input on that very question. Amazingly that is not asked. And so you can just imagine that's very devaluing.

It's not a matter of getting pizza from the administration. Those kinds of things don't really make us feel appreciated. Asking for input does.

Here's an example: I have this idea, this vision that right now during the Pandemic, if nurses only had ancillary support, much more ancillary support, the nurses could be maximised so much more. Ancillary support meaning nursing assistants, patient care technicians, different names depending on where in the country you are. Over the past few years, hospitals have scaled back nursing assistants and patient care technicians. Not done away with them, but, come close to.

So the nurses are out there doing all kinds of non RN work, answering phones all the time, wheeling patients out for discharge, stopping to make coffee and then delivering it. Now those are caring things and they're important. But in a time of crisis, I liken that to a surgeon on his way to do emergency surgery. And on the way he stops to answer a call light and he goes to fetch some tissue for a patient and bring it back. When he gets there the patient also needs to be re-positioned and they need help with food. Meanwhile the patine in surgery is waiting, It just doesn't make sense.

So, at a time when hospitals are paying oh, $8000, and upwards for traveling nurses a week... No, hospitals are paying more... that's what the nurses are earning... So we have to factor in the pay to the middleman, the agencies.

That's a lot of money. When you multiply that by the thousands, but then cut back on the lowest-paid staff who could do all that busy work, and make patients more comfortable. If we could just flip the hospitals and fill them with nursing assistants, patient care technicians, rather than cutting them back. How much nurses could do if the call lights were answered, if the phones were answered, if we had assistants there helping patients FaceTime their families! If their needs were anticipated and taken care of, helping to reposition, keep them clean keep them comfortable, and then nurses can do what nurses do. I wrote about it in Nurses Pushed to the Brink.

I've always said my whole career, almost everything I do, I can delegate to somebody else. I really am paid to think. That's what I do. I can assess patients. Finger sticks - anybody could do that. I could train them. Starting an IV - same thing. Inserting a Foley - anybody can be taught to do. In the home setting, you know, people do these things themselves. I'm just saying, it's not recognised that my value as a nurse, as a bedside nurse, is to think and assess the patient. To see a patient and then go…”Hmm...Their heart rate's up by 10 beats a minute, but yet they're just laying in bed. They don't have a fever, but they do have a source of infection"... and come to the conclusion that this patient might be septic, and take action. That's what we do.

And so we can maximise nurses just by adding more ancillary support. And when hospitals don't do this but order very highly paid travel nurses, it's what my dad used to call stepping over a dollar to pick up a dime.

And there's more. Nurses that are working in a hospital when travel nurses are brought in look at their new co-workers and go, "Whoa - Oh my goodness! So why don't they pay me five times as much for a couple of weeks?” It just breeds that kind of thing.

Joshua

Yeah, where they're helping the high paid person out all the time to help them...

Beth

I have a lot of respect for travel nurses. I want to go back and say, most travelers hit the floor running and they are saving lives right now. Literally saving lives.

Having said that, they don't have the organisational knowledge, they're just going to be here for a short time, it really wears on the regular staff. I mean, think about it. If you know someone's going to be here for only six weeks, you're just not going to invest as much in that relationship, therefore you lose teamwork. And teamwork among healthcare workers results in better outcomes. That's been proven.

So it's something we have to do right now, but it's not the answer and I think there are some other solutions that could be tried. But I have not heard of hospital one that goes to the nurses and says, "What would help?”... the questions that you're asking right now, Joshua. You were asking, "What makes it worse?... What makes it better?" They should be asking frontline nurses the same.

In California our nursing assistants can't even do finger sticks, because we're so regulated. So we have a lot of diabetics of course... so does everybody else... in the hospital. And with some, you're going to check the finger stick at least four times a day. If they're in ICU you're going to do it, maybe every hour. And in our state, only nurses can do that. That's preposterous.

Joshua

I'm just going to continue to comment to a redirect. That is a really, really important perspective and so glad to have you here sharing that. You probably remember, or you may have heard from Joan Toronto's work. She talks about, you know, part of what it means to be a caring democracy. A central part of this orientation is to actually listen to the people who receive care, and what they need, and what's important to them, but also the people who provide that care. It seems like what you're sort of dealing with is in a way a kind of lack of being consulted for your expertise. What do you think explains that? Is it a kind of, a sort of like a philosophical sort of mistake that explains this lack of putting the resources where they can really do the most good or enable the best nursing or is it sort of just like a top-down philosophical issue where people just haven't thought about the essential tasks in a certain sort of way? Is it that they're just not consulting nurses and asking them? Is there a sort of a missed priority as to what's important about medical care? Any thoughts about that?

Beth

It's a paternalistic system. I think being in the hospital industry takes you back in time... it's not progressive. They're a very conservative top-down, structure.

What else did you mention? Something else caught my ear.

Joshua

Prioritizing, thinking about what is valuable about care.

Beth

Value... Exactly! I mean, a lot of nurses feel that the value (as communicated by hospitals) is the bottom line. And there's a lack of good problem-solving skills. When people rush to a solution before they've clearly identified the problem, then you never fix the problem.

So people in the C Suite deciding on a solution without really understanding what the problem is. Because nurses are not valued enough to ask. You'll never, you'll never get good outcomes from that. So paternalistic. Again it goes back to not valuing what nurses really could contribute to make things better.

Joshua

Are there other social practices or policies, things we can be doing as individuals or collectively, that might enable nurses to better perform their essential work?

Beth

I think right now at this point in the crisis, what's going to change things the most, and I think all resources should be invested in this, is getting people vaccinated. That's what's going to turn this around. The vaccine distribution, the administration is just not very well coordinated right now as you know. There are vaccines sitting in refrigerators and they should be in people's arms.

If they could just somehow you know, come up with logistical policies and processes... It's kind of unfortunate that it's different by every state. It's not centrally organised at all. I mean the Federal government distributed, yes, the vaccines to the states, but after that, it was hands-off. Anyway, it's not going that well and so I think that would be the most important thing, that's what's going to turn the tide if anything. It's not going to get easier for anybody, for patients for nurses for anybody until we kind of get on top of this (mass vaccination).

Joshua

Right, absolutely. Speaking of vaccines. There have been some stories of healthcare professionals refusing to take the vaccines for one reason or the other. Have you had any experience with that or have you had any readers that maybe asked for your advice on whether they should take the vaccine?

Beth

I know there's some. It's really distressing to me to hear when healthcare workers don't want to take the vaccine because I believe it's what's going to change things. There is Vaccine Hesitancy, I wrote about it. We have to educate the public.

It perpetuates maybe some misconceptions when a healthcare worker doesn't want to take the vaccine. There are so many reasons for that. I don't know them all. Definitely, nurses that are pregnant are hesitant, which is understandable. Some entire communities feel that there's a lack of trust and that includes healthcare workers. It's a lack of trust in the healthcare system going long back in history.

Some people think it came out too fast and there are different reasons... they need to wait and see what the side effects are. You know, I can really just speak for myself. I'm a believer, I got my first vaccine. And I'm encouraging it whenever I get a chance to talk about it. For me, it's important to encourage everybody to get their vaccine.

Joshua

Right, absolutely, one of the central challenges and it doesn't appear, the kind of preparation that might have been useful. As you mentioned, not just individual states but across states is necessarily been done, even though that everybody knew that this would be a central logistical problem to preventing deaths once a vaccine became available.

Beth, I guess one final question, just sort of a sum up question which is what is your greatest concern for your fellow nurses, moving forward either in the US or globally and then, you know, sort of, what one or two things are reforms and you can simply highlight things you've talked about earlier if you'd like, would be most helpful to the profession?

Beth

You know, my hope for my fellow nurses is the same as my hope for any human being right now that we stay safe, that we can move forward, maybe when we get past this and be less divided. I really hope we can overcome some of our nation's problems that manifest in healthcare. I would like to see a really equitable health care system. I think we all would... one that we can hold it up as an example. And I think we have to be humble and learn from other countries that have contained the Pandemic better, what did they do, what did they do right, how can we better prepare for the next time? And I hope to see an increase in respect for nursing as a profession... to see an increased influence, and appreciation for everything that nurses do.

Joshua

Excellent. Thanks so much, Beth. That was a wonderful perspective. And thanks so much for joining me on the podcast. I know that listeners will really benefit from your insights and it was a great joy talking to you, and I learned a lot. Thanks so much.

Beth

Thank you very much.

Nursing in a Pandemic - Pandemic Ethics Podcast with Nurse Beth

Nurses, what is your greatest concern for your fellow nurses moving forward through this Pandemic?

What practices or policies can make it easier (or harder) for you to continue to perform your essential work effectively?

About Nurse Beth, MSN

Share on other sites

More Like This