MNA nurses and health professionals cite growing fatigue and stress of COVID care, inconsistent approach to COVID care, lack of testing for healthcare workforce, failure to properly isolate COVID patients, inadequate staffing to meet patients’ needs, and ongoing PPE concerns
As the state enters what appears to be an ominous second wave of the COVID-19 pandemic, the Massachusetts Nurses Association, which represents 23,000 nurses and healthcare professionals statewide, including frontline nurses working in 70 percent of the state’s acute care hospitals, reports that caregivers already exhausted and traumatized from the first surge have growing concerns about the current level of hospital industry preparedness.
In response, the MNA is calling on the state and healthcare executives to listen to frontline staff and implement their recommendations regarding the conditions, resources and support necessary to confront what is likely to be the most challenging phase of the pandemic.
“Nurses and other frontline healthcare professionals have been providing lifesaving care with dignity and resolve during this pandemic, oftentimes without the staffing, PPE or safety protocols in place to keep them safe,” said Katie Murphy, MNA president and an ICU nurse. “Throughout this crisis, MNA nurses and healthcare professionals have been advocating for safer policies and procedures to keep patients, caregivers and our communities safe. The lack of continuity on the state, federal and facility level on how to address this crisis demands that the voices of frontline nurse and healthcare professionals be heard. As we spend the most time with patients, and as confirmed by recent studies, we are at the greatest risk for infection if proper policies are not implemented and followed.”
To better protect patients and staff, below are key areas of concern raised by MNA nurses and healthcare professionals:
National Science-Based Mobilization of Resources
The first wave of this pandemic was met with little-to-no national leadership and a fragmented response coordinated by the states. The Centers for Disease Control and Prevention (CDC) and other health agencies were politicized, resulting in degraded standards and conflicting public health responses. Federal and state governments competed for a limited supply of PPE and other resources that resulted in our nation leading the world for the highest number of cases and deaths.
With a new incoming administration, nurses and health professionals call for a more effective and coordinated national response to this pandemic, with full use of the Defense Production Act to produce PPE, testing materials, treatments, and vaccines. We are pleased to see the new administration’s move to a response driven by science under the guidance of public health and infectious disease experts.
We also need to see Congress unite behind a robust relief package to support states and schools, rebuild the public health infrastructure, ensure hospitals and other providers the ability to provide the resources and staff to protect patients and communities, and provide financial support to those impacted by the economic fallout of the pandemic. Given that this pandemic has a greater impact on poorer communities and communities of color, these communities must be a priority for this federal support.
PPE Standards, Access and Transparency
Throughout this pandemic, nurses have seen the state and federal government, and individual healthcare facilities, promulgate varying standards of PPE utilization. These measures violated accepted standards of PPE use based on proper infectious disease protocols. The decisions to lower acceptable standards was not driven by science, but by inadequate supply chains, poor planning, and political expediency. Examples include the decision by hospitals during the first wave to allow nurses to reuse N95 masks multiple times even though they are meant to be used for a single procedure, or to force thousands of nurses to use masks decontaminated by unproven processes. Worse still, many hospitals failed to follow the MNA’s precautionary recommendations to utilize N95 masks as well as face shields or goggles for all patients at all times, instead hospitals were slow to implement use of masks and even when doing so opted only for procedural masks, discouraging the use of full PPE unless the patient was COVID-19 positive or undergoing an aerosolizing procedure.
As we long suspected, COVID-19 is transmitted not only by large droplets but by aerosolized particles – research indicates six-foot distancing is a minimum standard of safety, though it may not be adequate, and that 40% to 50% of cases are unknowingly transmitted by asymptomatic positive individuals. Considering this, all nurses and healthcare professionals providing direct patient care should have a new N95 mask at the beginning of each shift and they should be wearing shields or glasses/goggles as well.
Finally, we do not have detailed information on where facilities or the state stand on PPE supply because there has been a lack of transparency as to the supply and stockpiles of PPE. The MNA calls for a publicly disclosed, accurate and accessible accounting of the exact amount of each type of PPE held by every facility and the state. If we do not have adequate supplies to apply a basic minimum standard that sciences show is safe, this should be articulated to us now – otherwise it should be implemented universally and immediately.
Cohorting COVID Patients
At present, some hospitals are not appropriately cohorting COVID and potential COVID patients and staff to reduce the spread of infection. We are seeing facilities where nurses are getting both COVID and non-COVID patient assignments, and where COVID patients are placed in the same areas as non-COVID patients. For nurses and healthcare professionals, this mixing of assignments creates a greater demand for PPE and greater risk for exposure as staff move between positive and non-positive patients.
When we have raised this issue with hospital administrators, they voice concerns about the excessive burden on staff to care for COVID patients, and by mixing assignments they can spread out that burden. However, the only thing they are doing is increasing the spread of the virus around and risking losing more staff for prolonged periods. Patients must be cohorted and administrators should be negotiating with union nurses and healthcare professionals where appropriate, on how best to staff these units. We have in several places suggested recruiting voluntary staff for COVID-19 units with a commitment of a nurse working some number of weeks on the unit, and then being rotated out for a period of time so they are not burnt out from the stress of COVID care. The MNA also advocates for hospitals to develop designated proning teams, and other support staff to assist COVID nurses in donning and doffing, delivering supplies and other tasks.
Appropriate COVID Staffing
As stated above, the care of COVID patients is strenuous, complex, and stressful for staff. COVID positive patient can be acutely ill, require extra time for donning and doffing, meaning nurses must be able to care for a smaller number of patients to ensure patient safety and prevent their own exposure. Yet too many hospitals are not staffed to allow nurses the proper patient assignments to ensure patient or staff safety.
Unlike the first wave, when the state required the cancellation of all elective cases allowing staff to be redeployed to assist with the care of these highly acute COVID-19 patients, in the second wave elective cases continue, leaving nurses caring for COVID-19 patients short staffed for the type of care that has proven life saving for these patients. Hospitals must make every effort to fully staff their units and ensure that nurses and healthcare professionals have a safe patient assignment and quality working conditions. The federal government can support this effort by expanding the CARES Act funding stream to support these efforts.
The state must also consider rapid training programs for the workforce of other industries who have been laid off to assist in hospitals including field hospitals. A centralized hiring portal on the state’s website should be widely disseminated for use in order to deploy available skilled staff to appropriate sites.
Additional COVID Testing
College students and professional athletes are being tested repeatedly but healthcare workers, who have the most contact with the virus, still find it difficult in many places to get tested. We need more widespread, easily accessible rapid testing in the healthcare sector to better track the virus and help keep patients, staff and visitors protected.
Workplace COVID Exposure
Given the high rate of potential exposure to the virus for staff, it is important that policies be in place to ensure their safety and the safety of patients. We have been concerned to see the lack of clarity by the state and our hospitals as to protocols governing varying standards for quarantining of staff who are or who are suspected of being exposed, or recovering from the virus. There have been efforts to encourage asymptomatic nurses to return to work sooner than previously prescribed, which seems less based on science, and more to do with ensuring availability of staff.
We should not have better infectious disease standards being implemented in sectors outside of the hospital vs the healthcare setting themselves. Case in point: Several nurses who have had family members (children or spouses) become positive, informed the town, school, or spouses’ employer each of which indicated that they all quarantine for 14 days. The nurses contacted their employer and the employer stated that if they are not symptomatic, they must work their regular shift. This is not appropriate and, to the nurse’s credit in each case, the nurses indicated they would not come into work and would instead quarantine.
There should also be a uniform policy in every hospital for rigorous contact tracing. Nurses in hospitals have been reporting that they have been exposed to a known positive colleague and not notified.
The risks of exposure for frontline healthcare workers has been acknowledged again and again, most recently by a study from Mass General Hospital which observed that “frontline healthcare workers had a nearly 12-times higher risk of testing positive for COVID-19 compared with individuals in the general community” and that “those workers with inadequate access to personal protective equipment (PPE) had an even higher risk”[1]. And we know that many of our frontline healthcare workers have been working without proper PPE since the beginning of the pandemic due to shortages and various attempts to “conserve” lean supplies. This was only exacerbated when the CDC began to roll back infectious disease standards, which have demonstrated to increase exposure to the virus.
The MNA has pending legislation that would presume workplace exposure of COVID-19 for nurses and healthcare professionals who contract the virus. Many hospital executives claim their staff contract the virus from the community, which is inappropriate on two counts. First, frontline staff are potentially exposed in their facilities when they have inadequate PPE, have mixed assignments, or when they cannot socially distance in break rooms, shuttles, elevators, etc. Also, by not taking responsibility for workplace exposure, hospital executives are trying to avoid workers’ comp claims and are not assisting with data collection we need to track the long-term effects of the virus. As hospitals subject nurses and other caregivers, as well as their families, to increased risk for harm, they must be accountable for ensuring these caregivers are compensated for their sacrifice.
Paid Leave
Nurses and healthcare professionals on the frontline of the pandemic should not have to use their own earned time or go without pay if they are infected or need to quarantine. The lack of rapid easily accessible testing for the healthcare workforce has exacerbated this issue. This is another area where policies range widely depending on the facility. There needs to be a consistent, supportive approach. When caregivers can recover or safely isolate, it helps all of us stay protected.
No Hospital Closures or Service Cuts
Since the onset of the pandemic, we have seen the hospital industry use this as an opportunity to close a number of services including maternity, pediatric, psychiatric, emergency and other healthcare units, services that upon public review, the DPH declared to be “essential services for the public health of these communities.” Cape Cod Healthcare just cut midwife hours and Baystate Health still plans to close local mental health beds. This is completely unacceptable. During a pandemic, we need more services available, not fewer. The level of anxiety and heightened verbal and physical assault within the healthcare facilities is unmatched. This is directly related to the anxiety of the pandemic and limitations imposed on people but also as a result of the lack of behavioral health and emergency health services. People should not have to travel out of town or across the state for essential services. We have called on Gov. Baker to halt closures during this public health emergency, and we have legislation pending to strengthen hospital closure law.
Reopen Temporary COVID Field Hospital Facilities
The MNA is pleased to see the state re-establish the temporary COVID treatment site at the DCU Center in Worcester. Field hospitals in other cities should be activated as needed. However, efforts must be made to staff these facilities with the National Guard or with volunteers recruited and trained from outside of existing healthcare facilities, which need to maintain their existing staff for care in those facilities.
Vaccine Deployment
A positive recent development is the successful trials of vaccines now nearing emergency authorization. The MNA agrees with early indications that the priority first use of this vaccine will be with frontline healthcare workers who are so key to containing this virus. We support making the vaccine being made available to all healthcare workers and other essential workers. Given the truncated research and testing in order to bring the vaccine to usage for the pandemic, we believe a voluntary program, similar to DPH’s approach to the influenza vaccinations, with appropriate education is the appropriate method of deployment for those who have already put themselves at risk on the frontlines, and will result in overwhelming compliance.
“To advance the recommendations of nurses and healthcare professionals, the MNA is in regular communication with state leadership, and where the MNA represents nurses as a union, our members use their union rights to engage with hospital administration to improve COVID standards and practices to ensure the safety of staff, patients and our communities,” said Murphy, the MNA President. “We are reaching to the public now to inform them of these issues so everyone can understand the perspective of frontline caregivers and join with us in advocating for safe COVID conditions in all healthcare facilities.”
Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 23,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on healthcare issues affecting nurses and the public.
SOURCE Massachusetts Nurses Association
http://www.massnurses.org
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