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By now, we have all likely heard about the Massachusetts woman who killed her 3 children and attempted to kill herself as well. I will not mention her name because she does not deserve the shame. She was suffering from postpartum psychosis. She was a labor and delivery nurse. She was trying to get help, going to intensive therapy 3 times a week. Her husband was working from home in an effort to support her. What she did in her psychosis took less than 25 minutes while her husband went to pick up take out. With the media coverage this case continues to get, it feels wrong as a healthcare worker not to speak on it. This is an insurmountable tragedy, but not a criminal one. I don't know a single colleague who would say this mother deserves jail time, and I would be bold enough to question if anyone who would should be practicing in medicine. Postpartum psychosis affects 1 in 500 mothers after giving birth1. This is further different from postpartum blues and even postpartum depression, which also need to be taken more seriously than they currently are. Postpartum psychosis includes severe depression, delusions, manic mood, paranoia, hallucinations, and more. I will never forget when I was a nursing student in my OB course when my professor had a woman who had previously suffered from postpartum psychosis come tell us her story. I give her so much credit for being able to tell strangers these awful thoughts she had in an effort that it might make a difference for mothers in the future. This mom proceeded to tell us about intrusive thoughts she had, like when she was doing laundry would watch the washing machine swirl and imagine placing her baby inside, watching him drown and spin around along with the sheets. Years later, these were thoughts and missed moments with her son she was still mourning and trying to forgive herself for. These mothers lose themselves to this psychosis and typically need extensive help, including therapy, hospitalization, anti-psychotic medications, mood stabilizers, anti-depressants, and sometimes other interventions. I imagine this is why this Massachusetts husband came forward to say he forgives her and to ask others to do the same because he knows it was not his wife who did these things. I also imagine once she gets the help she needs, she will need much more again to cope with what she did. There are two key points to take away from this case and those like it. The first is that women need more care and support in the postpartum period. The second is that women's health needs more restructuring in general. Many women experience a variety of issues and changes postpartum after what their bodies just went through. Between the hormone surges, pain, lack of sleep, taking care of a newborn, and missing out on events or regular socialization, amongst other things, many experience loss of self, anxiety, depression, and stress. Too often, they are not screened well or just brushed off with a, "Welcome to motherhood.” It is time to shift and see this as the real concern it is. Preaching self-care to people who actually need community care is how we fail them. We as healthcare professionals need to not only be better advocates for our patients but work together to develop more resources for those who need them. This Massachusetts mother was in an area filled with more resources and medical professionals than some rural areas have in their entire state, and it still wasn't enough. It is not a failure on her but on the system. This is sadly not surprising when looking at other staggering numbers in women's medicine. While the list could go on and on, a key crisis in the US is our maternal mortality rate. The US continues to have the highest death rate related to childbirth compared to any other developed country and even often exceeds that of third-world countries2. In fact, in 2020, the death rate in the US was 23.8 per 100,000, a large marginal beyond even the next highest, which was France at 8.2 per 100,000. This is even further troublesome when looking at deeper data, such as the higher rates of death in women of minority groups, race, and social income/class. These rates only continue to rise. The maternal health system requires a lot of attention and restructure if we ever hope to see any of these rates go down and prevent deaths ranging from miscarriage to childbirth to the postpartum period across the entire continuum of care. It starts with access to care for all, followed by making changes to improve childbirth and prevent complications, and finally, ending with more support and resources in postpartum. Our healthcare system is long overdue for a paradigm shift focusing on improving the health and wellness of women and mothers, starting with the most important task of saving their lives. Thus I hope the attention rendered from this case can shift its focus from blaming this one mother for these poor little lives lost and instead, use it as an opportunity to address all these underlying issues in our communities to prevent any similar outcomes in the future. If there was ever a concrete call to action, this was it. References/Resources 1 Postpartum psychosis: National Health Service 2The Worsening U.S. Maternal Health Crisis in Three Graphs: The Century Foundation

I am a pediatric pulmonary nurse coordinator and remain per diem as a bedside NICU nurse. I made the decision to get vaccinated a couple of months after it became available at my hospital. As the vaccine was brand new, I put a lot of thought and research into it before making my decision. Ultimately, based on the facts I found and the science, I decided the benefits outweighed the risks. While I felt I would be okay if I were to get COVID, as I am relatively young and very healthy, we have all seen exceptions to this. However, I moreso felt a responsibility to those at higher risk in my personal life and my professional life—Most of all my vulnerable patients. I believe this reasoning was the driving force for a lot of healthcare workers to get vaccinated—more than just any fear of contracting COVID themselves. I think this is why we all get so emotional when it comes to still discussing the vaccine and the pandemic. In fact, just about a month ago after a particularly hard week, I could not wait to get home. It had been a week filled with parents arguing against the vaccine for their children. A week filled with ordering COVID tests for children who might end up hospitalized if they were to turn out positive. A week of writing school letters for patients to ensure accommodations that would keep them safe. A week of parents demanding letters from our section stating their child should be exempt from wearing a mask to school. A week of explaining to parents why we could not write that letter because their child would be safest with a mask. Not Making A Difference Due to these taxing conversations, it was no surprise how upset I became when I was driving home on my hour-long commute behind a bumper sticker that read, “Unmask our kids.” I tried to ignore it but it kept catching my eye until it eventually overwhelmed me and brought me to tears. Tears we have all cried during this pandemic, even if in different roles and different levels of care for our communities. Tears from being burnt out and unheard. Tears from being unappreciated. Tears from feeling like we are trying so hard, but not making enough of a difference. So where do we go from here, over a year and a half into this new way of life? When our co-workers and friends are refusing vaccinations, what can we do? They are people with the same basic training as us, but somehow do not view the science and statistics the same way. I have spent a lot of time contemplating this. In my opinion, it comes down to Roger’s diffusion of innovation theory. It Takes Time For Ideas To Gain A Following If you are not familiar, Roger’s diffusion of innovation theory essentially explains how it takes time for ideas or products to gain a following. The adoption of this idea or product happens throughout five stages or groups. First, we have the innovators, who make up just 2.5% of the population and seek out new ideas such as this vaccine. Next, we have the early adopters, 13.5%, who embrace change. After that, the early majority, 34%, who usually need to see some evidence of this idea or product and its success, but still adopt it before others. Then we have the late majority, 34%, who are skeptical, but once tried by the majority they will adopt the change. Finally, we have the laggards, the last 16%, who are very conservative to change, but may eventually give in to the majority because of things like pressure or fear. In terms of nursing, I usually consider myself the early adopter. I love to keep up on the latest research and changes. I get excited when I see a new study and think, “I want to implement that in my practice or on my unit!” However, when it came to the vaccine, I was more of the early majority. Since statistically, my personal risk was low, I thought it might be better for me to wait for more people to get vaccinated and see if any side effects appeared. However, as my coworkers began to get vaccinated and the momentum grew, I decided not to wait any longer. As stated before, I weighed my risk and benefits and from the statistics I had seen initially, I decided it was better to go for it. However, I think what makes me an excellent confidante for talking to coworkers as well as patients and their families about the COVID vaccine is that initial hesitancy I felt. We as healthcare workers know to assess risks versus benefits of everything. We also know that so many medications or products can come with side effects, however minimal. We have often seen first hand these very things, even after much research and FDA approval, get pulled off the market due to side effects that are not seen until much later. This is why we have a duty to do our due diligence, as I believe I did mine prior to deciding the vaccine was the best choice for me. This is also why I see the importance of discussing such controversial matters. Thus that is how I start these hard conversations. I do not dwell on politics. I do not attack people’s opinions. I do not insult people. I keep my emotions in check. I try to meet people where they are and understand what they are seeing. Now, albeit some people cannot be reasoned with, but in my opinion, those people only make up a fraction of the “laggard group.” So to have these conversations, I revert back to the basic building blocks of our careers—including therapeutic communication and being non-judgmental. This approach can give us the added bonus of not being as emotionally invested and thus help prevent additional burnout by these conversations. Use Psychology and Research In combination with these techniques, I try to use psychology and research to help make my case successful. For instance, when you listen and agree with the other person, you make them feel understood. This is as easy as, “If I were you, I would feel the same way if that was the information I had.” Not immediately disagreeing with people opens up a better line of communication and makes them more likely to also listen to your point of view. Personally, I actually do feel many who are hesitant do have valid concerns based on the knowledge they have. Additionally, we do not have to get defensive off the bat and we can ask to share our point of view as well. We can admit to certain shortcomings of the vaccine, such as how those who get vaccinated can still get COVID. We can then use this as an opportunity to explain why the vaccine is still beneficial, such as lessening symptoms. Trying to have an honest conversation where both parties are heard can truly have a profound impact in my experiences. Beyond that, a study looking at the adoption of evidence-based practice (EBP) using Roger’s diffusion of innovation theory found that adoption is influenced by individual motivation, attitude, knowledge, work experience, and the perception of EBP attributes. Interestingly, attitude was found to have the greatest effect on adoption of a change. The article suggests that changes should thus be promoted through, “use of cognitive principles that can change people’s attitudes in positive ways”1. I like to think this is similar to the approach I use based on therapeutic communication and psychology as described above. Take A Step Back Sometimes the best thing we can do whether we are at the bedside with one patient, speaking with a coworker, or trying to sway a group opinion, is just take a step back. Take a step back to breathe and listen. Give people space to express themselves and establish rapport. Remember that decisions take time and people all reach decisions differently, as we often see day to day in our field. While we feel the urge to get as many people vaccinated as quickly as possible in hopes that it will help rid our communities of COVID, we need to remember that we cannot simply force things onto people and expect them to happen. In a world where the past year and a half has been so complicated, we may need to simplify our approach to get the best results. We also may need to understand that while doing this work, based on the theory of diffusion, it may still take time. However, we need to keep having the difficult conversations until we begin to reach of late majority and laggards. There really is a light at the end of the tunnel, but unfortunately, adoption of change takes time and the COVID vaccine is no exception to this theory. However, by focusing on how we approach implementation, we can perhaps shorten this timeline. References 1Evaluating the adoption of evidence-based practice using Rogers’s diffusion of innovation theory: a model testing study

Any disaster brings in an influx of patients at a higher rate and volume than most hospitals are staffed for even on a good day. In fact, one hospital I used to work for only ever hired for 78% capacity because they usually averaged this census. If it's slower, some float, assignments are lighter, or people get called off. If it's busier, the staff has heavier, potentially unsafe assignments, and some people kindly come in for overtime. Occasionally some institutions utilize mandatory emergency staffing, like another hospital I worked at. Systems Are Not Perfect Unfortunately, these systems aren't perfect and work even less when disaster strikes. Sometimes, it's not as bad because if it's for a shorter time frame, such as after a shooting or explosion, people tighten the bootstraps or other hospitals come in to help. When the high demand is a little bit of a longer anticipated influx, such as during a natural disaster, people from all over can come help. You can get travel nurses or crisis personnel to come for a few weeks to that one affected area. But, what happens when the influx and crisis is all over? The way it is now during this global pandemic? Who is going to come save us and help us save our patients? Once a Nurse ... One thing states and other countries have been doing is calling on retired medical staff to come back into practice. Now, because we know the sayings, "Once a nurse, always a nurse,” and "A nurse isn't a job, it's who you are,” bravely many people stepped forward. Yet it still does not seem enough. And let's not forget staffing continues to fall everywhere as staff becomes ill or exposed themselves. Relaxing the Rules So hospitals are also calling on anyone with a license. We have even lifted rules so that people can practice medicine in a state different from the one in which their license is held. But, how many people who are staffed in one area are really able to move across state lines to help another, when their own state is also in crisis? "Crisis Pay" My friends, colleagues, and I all keep receiving texts, calls, emails, and LinkedIn messages to come work for a few weeks or with essentially entire job offers on the table because of the high demand. Most recently, my friend received an email stating that nurses are urgently needed to help provide care during COVID-19 staffing shortages. The key I want to zone in on is the second part of that email: The compensation. Crisis pay. Up to $4,700 a week. This is more than most nurses make in an entire month, although I suppose it varies a little more depending on your state and cost of living. This offer is for 8-week assignments, 12-hour shifts with 3 or 4 shifts per week at $103/hr. Now, the Questions Why are we not making these offers to our own staff? On a unit level, a hospital level, or state level? This is what I asked my friend when she told me about this email. Because otherwise, the only people they are really appealing to are travelers and those who happen to be out of work at this time. I mean, it's not like she or I can leave our current jobs and move over to the next state for the next 8 weeks while our own hospital needs more staff and likely wouldn't accept us back afterward. Nursing Staff Deserve It I am not even saying that we need to suddenly increase base pay to "crisis pay" for everyone already working. I am sure there are those who would argue this and likely with some valid points. However, in the interest of being reasonable, I am arguing that staff deserves crisis pay or at least double pay for anything worked above their regularly scheduled hours. Why? Because there are many people who do not even want to work their regular hours at this time. This is mainly because they are scared to work in these conditions without proper PPE supply or because they are terrified of bringing the virus home to their families. They are also doing a lot more work than on a regular day and under more stressful conditions. However, they would be more willing to do this with fair compensation. Other Compensation Do you know why some healthcare professionals are asking for hazard pay or student loan forgiveness? It's not because they feel above their work. It's because they want some sort of compensation for doing at least double the work that should be required of any one person. It's because they want to feel some sort of support for putting themselves at risk. It's because they want to feel VALUED. There Are Staff Shortages Everywhere Right Now We can't keep hoping that somehow people will come out of the woodwork to save our own hospitals because everyone is busy weathering their own storms. However, our own staff would likely be willing to help during these shortages with some incentive because in healthcare we always pull together as a team. I think this would also help hospitals from forcing staff to float to units or specialties they do not feel competent or safe working in. Back to that Email ... Hence, to circle back around to that email my friend got, my response to her was the realization that if our hospitals or even others within our own state did that and on more of "committed per diem basis" if you will, I would pick up a shift at least one day a week. She said the same. I think if we did a poll, a high percentage of healthcare professionals would also agree. Hospitals need to realize this and capitalize on it to create more of a win-win situation (as much as you can consider things a win under disaster). Now is Not a time for Penny-Pinching Our Dedicated Nursing Staff It's no secret that adequate staffing is linked to better patient outcomes. You can easily search and find that good staffing equates to less falls, less pressure injuries, and even higher survival rates. The list goes on and on. So it is crucial for a time like this. A Win-Win Beyond that, in the long run, I do believe that if someone sat and crunched all the numbers, paying staff either hazard pay, double time for any time worked over their regular hours, or whatever incentive system thought of—this would still equate to a less overall cost loss for hospitals than not doing so. While it is likely many hospitals will suffer costs from workers falling sick, getting these travelers, or buying more equipment, we all know the high costs associated with negative outcomes and these are going to be higher than ever. And while I do not know for sure, I imagine insurance companies will not be cutting hospitals a break about their rule to not reimburse for hospital-acquired conditions. And, who is best at being able to prevent these conditions? It is the staff at the frontline with direct patient contact. So, Hospitals and States ... ... start placing more value and respect into your own loyal team. Rather than forcing your staff to work in other areas while offering astonishing packages to outsiders, give those benefits to your staff for picking up extra shifts or floating elsewhere. This Nursing staff delivers for your organization and community on a regular basis. They deserve the recognition. They deserve the profit. They deserve to receive a taste of what they are worth. This is not a time during which you will be able to pull more staff out of thin air, so it is time to start utilizing your own through those same measures. Loyalty goes both ways.

I'm a little late-- but have you talked to your child's doctor? For some of my asthma patients and cystic fibrosis patients, we have gotten calls from parents who work in different areas--including Navy, nurse on an adult pulm floor, and pharmacy--and because they are worried about their child we wrote a letter to their employers to figure out alternate ways for them to work or to not work at all and stay home because of the risk to their children. We use a letter template provided by Compass (a CF organization) that states this, then states it is in the interest of the child, and references a paragraph on these patients being protected under law. Actually...let me see if I can show you here: Re: Letter requesting accommodations for remote or work alternatives Patient: DOB: To Whom It May Concern: On behalf of my patient, [ X ], I am requesting that [his/her] [mother/father] be given the opportunity to work remotely or be provided alternative accommodations to distance [him/herself] from others. My patient has cystic fibrosis (CF), a progressive lung disease which may put [him/her] at greater risk of developing serious illness from COVID-19. The CDC has issued guidelines for people who are at higher risk -- including avoiding large gatherings, such as the work place and staying home as much as possible as extra precautions to put distance between themselves and other people. Individuals with chronic illness, like CF, are considered a protected class under the Americans with Disabilities Act (ADA). Considering the current state of risk for exposure to COVID-19, all possible accommodations should be made out of consideration for [X’s] medical condition. Thank you for considering this request. Please feel free to contact me with any additional questions or concerns you may have at ( ). Sincerely, I use this template and fit it to patient and his/her medical conditions whether asthma or PCD or what have you. You should ask your child's doctor.