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Nurses have experienced some of the most intense moments in nursing history during the COVID-19 pandemic. They worked to protect the public, often at the risk of their own physical and mental health. Yet, many nurses expressed that they did not feel equipped or trained to respond to this pandemic.
Nurses are on the frontline of public health emergencies, including pandemics, environmental disasters, and mass casualty events. The nursing workforce must be prepared to respond to these events, and be protected as they respond. In this episode, frontline nurses share about their experiences responding to the COVID-19 pandemic and other public health emergencies, and explore how nurses should be strengthened, prepared, and protected for the next emergency.
The United States has some of the poorest health outcomes. Health disparities run deep, leaving many people without equal opportunity or access to care. As long-time advocates for health equity, nurses are in unique positions to address the root causes of poor health, reduce health disparities, and improve the health and well-being of the nation.
In this 8-part series from the National Academy of Medicine, we explore practical strategies for the nursing profession to advance health equity. We’ll hear stories and experiences of frontline nurses and other health experts from a wide range of settings. These strategies reflect the recommendations from the report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.
If you’re a nurse, involved in any health sector, or want to know how to create a better future for all Americans through improved health outcomes, this podcast is for you.
Dr. Sharmaine Lawson (00:15):
West Virginia has a history of poor health outcomes. Many people experience food insecurity and financial instability. West Virginia is rural, and this makes it difficult for people to find transportation that allows them to access care. The COVID-19 pandemic only magnified these problems. Angela Gray is a public health nurse who's worked in West Virginia for over 15 years. She's now the Nursing Director for the Berkeley and Morgan County Health Departments. Angela grew up in Morgan County, West Virginia, and she's seen these poor health outcomes unfold, but she had never seen an emergency quite like the global pandemic.
Angela Gray (00:58):
I felt that we had done all these drills. I've been through H1N1, through mass vaccination in the past, but nothing compared to this. There were several key points that I know where I thought they didn't prepare us for this. When New York got hit so hard and you saw the refrigerator trucks come out for the bodies, I knew that would happen. That was in our training to expect that. It was very surreal to see it happen, believe me.
Dr. Sharmaine Lawson (01:30):
From the start of 2020 up through 2021, nurses underwent some of the most intense moments in nursing history with the COVID-19 pandemic. They worked hours upon hours to protect the public, and often at risk of their own physical and mental health. In this episode, we are going to hear from frontline nurses about their experiences and together, we are going to explore how nurses can be strengthened, prepared, and protected for when the next emergency strikes.
Dr. Sharmaine Lawson (02:13):
This is the Future of Nursing, a series from the National Academy of Medicine, based on the recently published report, The Future of Nursing 2020 to 2030, charting a path to achieve health equity. I'm Dr. Sharmaine Lawson. At first, when the pandemic began, Angela Gray saw glimpses of hope.
Angela Gray (02:33):
In the beginning, it was ... really restored your faith in humanity as you saw the country come together. People were so grateful, and we were calling people who were positive for COVID and helping them and their families through it. Then at one point after a couple months, it was like somebody turned a switch and then people became very angry. We got cussed more in a day just for trying to do our jobs and collect the data points that was required for us to report.
Dr. Sharmaine Lawson (03:02):
When Angela saw this shift in the public, she knew it would take a big toll on the nursing workforce.
Angela Gray (03:09):
It was very tough in that transition of, oh my gosh, we're the people here that are trying to help you, and they're blaming us because we're the ones that are out there trying to make sure the guidelines are being met and the recommendations are being met. So yeah, it was very difficult and it really hit our mental health. By October of 2020, I had four staff members that disclosed that they had to go to their physician to get on anti-anxiety medication or medications to help them sleep. That was just the staff members that disclosed to me. So I try to advocate for us here.
Dr. Sharmaine Lawson (03:48):
Backlash from the public was one reason why nurses' mental health suffered. It wasn't just their mental health that suffered, but their physical health as well.
Angela Gray (03:58):
By that time in September, they had mandated that our National Guard be off two days a week because they had already seen the stress under them, but nobody was advocating for us. I'm like, "Look, we're working seven days a week for months on end, 12 and 16 plus hour shifts. We're taking on so much." I said we can't continue these long stretches like this. You're not going to have any of us left. So then they, our administrator, stuck up for us and said, okay, I'm going to mandate everybody have off two days. So some people got that. Some of us didn't because even if you were supposed to be off, your phone never stopped. You just could not get away from it. It was literally consumed every aspect of your life.
Dr. Sharmaine Lawson (04:44):
Nurses across the country were fatigued. They couldn't always just rest from their duties. They put their own health and wellbeing at risk to protect the public. Dr. Michael McGinnis is the Leonard D. Schaeffer Executive Officer of the National Academy of Medicine. We heard from him in an earlier episode. Dr. McGinnis watched as nurses, Physical and mental health went under extreme pressure, and he discovered something that was concerning. Most nurses did not feel prepared for this.
Dr. Michael McGinnis (05:16):
Nurses were thrown quite abruptly during the COVID-19 pandemic onto very front lines in very hazardous conditions. The effective function of the system was fundamentally anchored to their effectiveness. Yet four out of five nurses, when asked whether they felt equipped and trained adequately to be able to contend with emergency circumstances, whether related to the COVID-19 pandemic, or related to other external threats to the nation, or emergent situations, felt that they didn't have the training.
Dr. Sharmaine Lawson (05:56):
Public health emergencies can be caused by transmissible diseases, but can also be caused by environmental disasters and mass casualty events. In the past decade, 2.6 billion people around the world have been affected by earthquakes, floods, hurricanes, and other natural disasters. The COVID-19 pandemic is just one example of a public health emergency. When disasters strike, nurses can engage the community and build trust with them. They can educate and protect them. They can also help people prepare and respond. When it's time for the community to recover, nurses can help people to foster resilience. Nurses may go through training that prepares them to respond to these emergencies, but often it isn't enough, and many are left unprepared. Dr. Roberta Lavin is a nurse practitioner who spent much of her career on disaster preparedness and response. She's recognized that there are some areas in nurses' training that demonstrate a lack of preparedness among nurses when it comes to public health emergencies.
Dr. Roberta Lavin (07:05):
In my discussions with many nurses, I've been told that they've had little to no training after graduation from nursing school, and much of the training is provided to those in the emergency department and to administrators, and not to the average nurse on a unit. The second area is lack of serious disaster preparedness planning that involves nurses. The quote that struck me was one that said, "We train people to put out a fire, but not how to evacuate the patients during the fire." The same can be said for how we handle infectious diseases. We train people what they should do to handle infectious diseases, but we never have them practice donning and doffing of the PPE that they need to use.
Dr. Sharmaine Lawson (08:00):
According to Dr. Lavin, we have to act now to really prepare the nursing workforce for disaster response.
Dr. Roberta Lavin (08:07):
We know that we've always said that this is the time we have learned the lessons from the pandemic. We do after actions and we put the things together and then we say we're going to fix them. We said after 9/11 and the anthrax attacks, never again. Then Katrina and Rita came, and we weren't prepared. Again, we said never again, and Puerto Rico came, and we weren't prepared. We said, never again, and then this pandemic came. Maybe this will be the time that we take the lessons we learn.
Dr. Sharmaine Lawson (08:44):
It's imperative that we do learn from these lessons because natural and environmental disasters are happening more frequently. Public health emergencies, like the COVID-19 pandemic are inevitable, and our nursing workforce must be prepared, along with our health system, to protect our nurses as they work to protect us.
Dr. Sharmaine Lawson (09:10):
Public health emergencies can take many forms. They can be global, national, or contained in a local community. Prior to the COVID-19 pandemic, Angela Gray had her own experience with other public health emergencies in West Virginia. While these cases happen in West Virginia, they also frequently happen all across the nation.
Angela Gray (09:33):
Sure, I think the opioid epidemic is a perfect example of a public health crisis in this country, versus something communicable like COVID virus and pandemic. So we're always looking at these emergencies, and depending on the research and the data of where the numbers are and the stats are and what's happening, chronic disease in West Virginia is huge rates higher than other parts of the country. Even in the same country, you may be working on different needs based upon your community and what the threats are in your individual communities. It might be the same all the way through the nation. It's just, it can be very different in different areas of the nation. Here in West Virginia, teen pregnancy, chronic disease and illness, diabetes, substance use disorder.
Angela Gray (10:16):
We had a huge hepatitis A outbreak that the country usually sees less than 1500 cases in a year. West Virginia usually sees less than 15 cases, and we ended up with 2,500 cases in West Virginia in one year. So that triggers our response of getting out and trying to vaccinate, getting ahead of it, trying to contain it. So lots of emergencies, and then also down to we would respond and support our other community entities if it would be a water spill or a contamination of water on the environmental side of public health. There's multiple things that we're doing behind the scenes every day, protecting our communities so everybody can go about their way and feel safe.
Dr. Sharmaine Lawson (10:59):
When nurses are equipped to respond to disasters and other public health emergencies, communities can become safer and care can be delivered even in the midst of a crisis. But as of right now, many nurses admit they do not feel equipped to respond to these kinds of events. Because they are not prepared for disaster and public health emergency response, rapid action is needed. So what can be done? First nurses and nursing leaders must understand what their roles are in public health emergencies and natural disasters, training programs should consistently address what these roles are, so that when a public emergency occurs, nurses can be confident of how they are expected to respond. We also need reform in nursing education, practice, policy, and research to address the gaps in nursing disaster preparedness. We need experts from nurses to researchers to develop a national strategic plan that then addresses these gaps, figures out how they can be solved, and whose responsibility it is to implement new strategies.
Dr. Sharmaine Lawson (12:15):
This action is especially important as nurses are often addressing health inequities while responding to public emergencies. With preparation, nurses may feel more confident in their ability to respond to crises. We can never fully mitigate the stress that public health emergencies can cause for nurses, but we can work to lessen the trauma they may experience due to the disaster. Derek DeSilva is a young intensive care unit nurse who practices at a hospital in Austin. Derek had begun working on the ICU floor just a few months before the COVID-19 pandemic began. He felt like he had a good grasp on how the floor worked. He had even gone through some emergency preparedness curriculum in nursing school. But then everything changed and he realized he wasn't prepared for this at all.
Derek DeSilva (13:05):
Whether that be in nursing school, hospital staff, people, disaster management organizers, the idea of a widespread pandemic wasn't something that we were prepared for, really coached about, or given any extra resources.
Dr. Sharmaine Lawson (13:20):
Positive cases of COVID began increasing. As the ICU began to fill with COVID patients, Derek watched as existing health inequities were magnified.
Derek DeSilva (13:31):
I definitely noticed quite a few of these health disparities. Typically, they surround around having health insurance. Some patients would massively benefit from being able to transfer to more specific facilities, or being able to be eligible for certain medical treatments that they simply did not get access to because they didn't have health insurance. Where we had them, as as much of their health that we could rebuild in in our unit, that's as good as they were going to get, because without insurance, they weren't going to be able to transfer to that facility. So these patients were basically stuck in our ICU. They couldn't progress to the level of care that they absolutely could and would need simply because they did not have health insurance, and it would not approve for these life bettering, life saving procedures.
Derek DeSilva (14:29):
Before maybe not having insurance would be missing out on an opportunity to maybe gain more mobility, or have some specialized training to maybe learn how to eat again after a stroke. But during the COVID-19 pandemic, not having insurance for some people meant that they were going to die.
Dr. Sharmaine Lawson (14:49):
Derek and nurses across the world witnessed devastating outcomes due to this pandemic. Many nurses were often the ones who held the hand of a dying individual. They'd call family members of patients so they could say their last goodbyes. Some nurses even sang a last song for the patients who would not be leaving the hospital. These were often just short, significant moments, and nurses often had to quickly move on to assist another individual. Nurses were not prepared for the trauma that came from witnessing these terrible outcomes. Health systems quickly realized that their nurses were under incredible pressure. They worked to provide resources to support their nurses through these intense and very sad moments.
Derek DeSilva (15:37):
Our hospital system was actually really good about providing some mental health services, about providing some outlets. We got free basically telehealth counseling sessions to be able to talk about it. A lot of people, a lot of nurses, a lot of medical professionals were able to just get together after some shifts and talk about some things, but it was nice to know that there was at least some support and it was totally free. You got to use those, and I've got quite a few colleagues who were able to use these telehealth counseling sessions or mental health sessions, or so to be able to just decompress and talk about some of the things, talk about everything that happened.
Dr. Sharmaine Lawson (16:27):
This support was helpful and helped to ease some of the burden nurses experienced. But it didn't take this burden completely away, and not all health systems and employers were prepared or equipped to guide nurses through this time long term.
Derek DeSilva (16:43):
It was good to get some support from management, but at the same time, it wasn't like management could give you a break. It wasn't like the hospital suddenly stopped when you got burnt out. They were still asking for extra shifts. They were still asking for people to come in and pick up extra, like I said, all the way to even January of 2021. So it was good that there was some support. There was some ways to talk about things, but getting burned out was a very real thing for a lot of nurses. It almost seems like that's the kind of support that we needed more. But things changed early on, early March to July, March to August. Having someone to talk to that was the biggest thing after that second wave. Like I said, at least in Austin area, a second wave happened around July.
Derek DeSilva (17:36):
Having more resources and more personnel would've been the next kind of support, I think, that a lot of people were looking for, just because of how burned out everyone was getting from picking up so much extra. Maybe during these situations, people are going to be dying every day. That's the reality, and I feel like we are so desensitized to that now. We're ready for a situation like that. But talking about it, I mean, we in nursing school, in hospital orientation, I think we get some information about make sure you do self-care, make sure you're checking in with yourself, but even going to the ICU, it doesn't seem like there's a lot of real preparation. I think the same could be said for the emergency department as well. There's some stuff you're going to see there, and people are going to die in those places. Is there really a way to prepare you for that?
Dr. Sharmaine Lawson (18:38):
Providing resources for counseling and support is beneficial, but hospitals and health systems must also have a systematic approach to support their nurses when a public health emergency begins. In an earlier episode, we talked with Frank Boz. Frank is a nurse in the cardiothoracic intensive care unit. In our episode on supporting nurses, Frank shared how the leadership at his hospital supported him in an unexpected way. This kind of support may have cost the hospital resources, or required them to change policies, but it gave nurses a voice. It gave them a chance to better understand what to expect as procedures shifted. In our supporting nurses episode, we also talk with Marcus Henderson, who is a practicing psychiatric mental health nurse and member of The Future of Nursing 2020-2030 consensus study committee. During the pandemic, Marcus saw that it was critical for hospitals to invest resources in finding creative solutions to protect and support nurses during public health emergencies.
Marcus Henderson (19:42):
There's a lot of work to be done if less than 10% of hospitals have bit the bullet to say, "We're going to show that we invest in nursing." So I think there is still a lot of work to be done. It comes in pockets, and I think COVID has shown us that these workforce issues related to staffing shortages, burnout, resourcing have not gone away, and in some places have exacerbated greatly because of the challenges that COVID has imposed. But I think it has shown us the creative solutions that can be developed. But I do think there is much work to be done.
Marcus Henderson (20:21):
I mean, it's crazy to think that when a nurse reaches out for help and support, for example, reaching out for mental health support, that they're penalized and their ability to function at as a nurse is called into question. Rather than providing that nurse with the support that they reached out for to do their job better and to progress. So we have to change the whole framework and the whole culture around support and wellbeing, because people see nurses that reach out for support as a deficiency and not an area for growth.
Dr. Sharmaine Lawson (20:57):
Derek DeSilva found that there was yet another specific kind of support nurses really needed, especially since for many nurses, a public health emergency is only one example of a situation that might cause trauma for nurses. Outside of emergencies, nurses still encounter emotional and difficult situations, whether in the ICU or another floor in the hospital or in a public health setting.
Derek DeSilva (21:21):
I think the biggest thing that would help nurses is other nurses. I think the biggest way that I learned, and for a lot of other nurses as well, is getting to talk with some nurses who have experience, who have lived through some of these situations. Saying, "Yeah, I was working, like I said, 50, 60 hour weeks for an entire month, and I got ... I started getting burned out," and talking about burnout. This is something that happens with new nurses all the time. Being able to talk with someone who had the same experience, who was a young nurse at one point as well, and have seen many other nurses make similar mistakes or go down a similar path, and I found that to be valuable. Having other nurses, having experienced nurses who have gone through similar situations talk to you, or talk to newer nurses and say, "Hey, these are the things to look out for. Watch out when you feel yourself starting to feel more upset or not excited to come into work. Be mindful that it's more about the patients."
Derek DeSilva (22:22):
I think in one sense, maybe in nursing school, having nursing students talk with individuals who have gone some of those situations, some of those public health emergencies, I think it would be extremely valuable.
Dr. Sharmaine Lawson (22:35):
Or Derek, this was one way he knew nurses could be protected through public health emergencies specifically by supporting each other. But there was something else nurses needed, especially during the pandemic, as policies and guidelines frequently shifted.
Derek DeSilva (22:51):
A lot of what we do, pretty much everything we do has 10, 20 years, quite a few decades of best practices that have only been improved upon as the years, as the decades have gone on. To have something that we don't have best practices for, that it seems like we're making and things up as we're going along, I think that scared people. I think what could be done in the future to mitigate the fear that nurses had with all of these changing procedures is to use what we've learned from this last pandemic. To be honest that when something new comes up, when something outside of our scope of expectation and preparation comes up, that they need to expect some of the procedures to change as the science evolves.
Dr. Sharmaine Lawson (23:38):
Nurses around the nation, even around the world now understand that when an emergency like a pandemic is occurring, procedures are guaranteed to change. Education and training should prepare nurses for these changes so they can know to expect them and move forward with confidence. This is just one example of the many lessons learned from the COVID-19 pandemic. Like Dr. Lavin mentioned earlier, this time, we must take these lessons into consideration and act on them.
Derek DeSilva (24:09):
Hey, if this happens, we're going to try to call and retain these nurses, or something to that extent, giving a little bit more importance on the fact that something like this could be possible. We do CPR training every two year years. We re-up that CPR training every two years, and we stay keen. We know exactly what we're looking for, and we get a refresher. We do fire drills now almost monthly. So I think incorporating this, and talking to newer nurses, and incorporating this in hospital orientation could have the chance to just make it seem a little less scary and give people a little bit more understanding as far as the expectations. You're not going to have 100% premonition of what's going to happen, but at least having some idea of expectations going in, I think might do wonders for the new generation of nurses who are just coming to the field.
Dr. Sharmaine Lawson (25:07):
We have to understand that by strengthening and preparing nurses to respond to the next emergency, we are also protecting them. The physical risk can't always be taken away, but they can be mitigated when we equip our nurses to be confident in their knowledge, skills, and resilience.
Dr. Sharmaine Lawson (25:30):
We want to take this moment to honor the nurses around the world who paid the ultimate price of caring for people during the COVID-19 crisis. To the nurses who are still working on the front lines to protect the public, your dedication and persistence in the face of adversity has saved countless lives. We look to you for the future of nursing to help ensure that what happened to the nursing profession this year and those in their care, especially the disadvantaged and people of color, that this all becomes an event of the past.
Dr. Sharmaine Lawson (26:10):
The COVID-19 pandemic is just one example of how disasters and public health emergencies can cause a significant burden on the health of populations, healthcare professionals, and nurses in particular. The pandemic made it very difficult to manage its effects on diverse and highly vulnerable populations. Existing health inequities were exacerbated. Like we mentioned before, future natural disasters and infectious disease outbreaks are inevitable, and they will present similar, maybe even greater challenges for the nursing profession. Therefore, bold action is needed to help our nurses be ready and prepared for these events.
Dr. Sharmaine Lawson (26:56):
If you want to learn more about what your organization can do to strengthen, prepare, and protect nurses during public health emergencies, check out The Future of Nursing 2020-2030 report. You can visit the homepage at nap.edu/nursing2030. As always, thanks for listening.