A deeper look at how nurses are affected during the current health pandemic.
Janae Sharp, Founder, Sharp Index
'Let me feel safe' — This nurse stood her ground and quit her job after being asked to work in a COVID-19 unit without a mask pic.twitter.com/13bhs8meNP
— NowThis (@nowthisnews) April 1, 2020
Imagine going to work and knowing you or your loved ones might die if you show up. No one is protecting you, and the scant supplies to protect you aren’t arriving. In the unprecedented situation caused by coronavirus disease 2019 (COVID-19), nurses are working increased hours in unsafe, under-resourced conditions, putting their own health at risk—and at the same time, increasingly becoming the front-line in crisis communication. “There are an array of challenges,” says Bambi Gore, MSN, FNP-BC vice president and chief clinical officer of Simplifi, a hospital staffing company. “The front-line staff are becoming symptomatic, and there are varying guidelines on what to do or not to do when symptomatic—some hospitals don’t make nurses quarantine until they have all the symptoms, some quarantine with some. There’s total inconsistency, not nearly enough tests, and screenings are prioritized for patients. Healthcare workers are not prioritized for testing.”
The result, according to Gore, is a dearth of nurses who are cancelling because of homebound children, illness, or fear just when the need for skilled nurses is most desperate. Gore cites lack of personal protective equipment (PPE) as another exacerbating circumstance—1 hospital uses N95 masks while another only uses face shields, causing significant anxiety and confusion among the tight-knit community, and nurses are being forced to re-use PPE.
Moreover, she says, nurses are having to make hard decisions on who gets the ventilator, who is the sickest, who dies, and who gets care.
“Lots of ethical decisions,” Gore says.
Creating an environment where ethical decisions are fair to nurses and patients will require work. That’s what Rhonda Collins, DNP, RN, and chief nursing officer at Vocera, has been focused on. In a crisis situation, the Vocera team is trying to make the best decisions possible—and in the absence of certainty or clarity, it is forced to improvise more protocols and processes. Collins and her team have focused on decreasing the stress of communication during crisis care. When humans have too much information to process, their short-term memory is impacted. This is referred to as your cognitive load. Everyone has a discrete amount of “working memory.” In times of crisis, whether nationally or personally, the amount of memory that is being used is greater. Nurse leaders recently published the implications of cognitive overload for those in their position.
According to their research, cognitive overload can lead to incorrect decision-making (resulting in lower quality of care), as well as lower job satisfaction and retention of vital medical professionals.
“Last year, they were just starting to talk about it, and how nurse executives think about it,” Rhonda Collins, DNP, RN, FAAN says. “We wondered, ‘Is everyone even aware of it?’ People put things under this big umbrella of burnout. If you ignore the cognitive overload, it’s too late. You need to start addressing the components that are building to these burnout situations.”
“One of the things we see in these professions that require a high level of commitment is what cognitive overload does to the practitioners,” Collins says.
Cognitive overload, Collins explains, is a simple information management issue.
“It relies on where you are personally,” she says. “If you have chronically ill parents or children, you carry that with you. Some days that will come to the forefront. It’s the backpack that you can’t take off—the family, the finances, the response to all of that. There are some people who can tuck that away. But then, there are days when that collides.”
Technology can help with the cognitive burden. One of the greatest stressors for medical professionals, particularly in times of crisis, is specifically remembering data. Numerous studies have shown that short-term memory is adversely impacted by cognitive burden. The ability to sort information, in particular, is undermined. Technology can ease the burden of sorting— treatment information, lab results, prescriptions, patient follow-ups—enabling nurses to focus more on face-to-face interactions.
But what does cognitive overload have to do with a crisis? In a crisis situation, such as the COVID-19 epidemic, great technology and great support still might not be enough.
“How many people can just get up and start work?” Collins asks. “Clinicians are expected to do that and take what comes at them. They are expected to just change the rules and move the patients through the system based on a changing environment.”
Collins says that information, in this scenario, needs to not only be available, but actionable.
Technology can be used to sort through urgent tasks—to send information to the partner, the charge nurse, or the attending physician—making sure that the patient isn’t forgotten. We expect a cognitive load that is untenable, so support and technology for nurses will mean the difference between life and death for patients.Coordinating a patient’s care can be like a wheel, with nurses at the center coordinating care. Physicians are a spoke in the wheel; the dietary team is a spoke. The nurse has to take all the information and communicate it through the individual patient’s care team. There is a fundamental fact that physicians and nurses communicate differently.
Collins says that physicians give cognitive load to nurses and, as she says, “No one asks how you like to be communicated with.” Everyone has a different preference about the continuum of care, and nurses have to internalize communication preferences for multiple people. They have to put lab values for the patients into context of previous values and integrate with the treatment plan. If nurses are given a discrete lab value without context, they have to sort through the test results and find out context and connection. This can mean coordinating with a care team that is not available. Then they take the message to the physician, according to the physician's preference.
“Physicians do not work off of discrete data points,” Collins says. “Nurses have to take each data point as a whole and put it into the story of the patient. This involves interpreting and sorting data. It adds another layer of management.”
Figuring out how to contact care team members has little value in driving appropriate outcomes when nurses are also trying to coordinate care. In a crisis, it can mean urgent cases don’t get seen in time. When everyone is short on time, it’s important to have faster and better data interpretation and communication, with less effort. Nurses should be able to stay in PPE and use voice technology to communicate needs. A read receipt after sending a verbal message is more helpful than a pager. With COVID-19, it can significantly impact the number of lives saved, including the lives of nurses.
However, capacity is driven lower every time a nurse falls sick because they provided care without the proper protection.😷 pic.twitter.com/a6yRAkPD2P
— Bonnie Castillo (@NNUBonnie) March 28, 2020
In spite of any mitigating technological innovations, however, it looks increasingly likely that the COVID-19 crisis will change the future of nursing, and the ease with which hospitals can staff their positions. Many surgeries are being delayed. When this surge abates, we will have another surge, from those delays.
Bambi Gore cites the current shortage in OR nurses, resulting in the price to hire them becoming “astronomical.”
“ICU and PCU nurse needs are in surge,” she says. “We have been working with our largest clients to utilize OR nurses in a ‘helping hands’ manner—under the RN scope of practice, they can still hang medications, ambulate patients, start IV’s, or insert catheters, without accepting responsibility for a patient assignment in a specialty that is outside their scope. The difficult part is trying to keep a good balance of staff that you may need 2 weeks from now or 10 weeks from now, when they resume surgeries.”
Gore also explains that regional “float pools” are being created to address the current needs, wherein nurses who are aligned to a geographic area and multiple specialties would be able to float between 5 hospitals, potentially filling positions in the ICU or the PCU.
“Day to day, the shifts where they’re needed could change,” she says.
The cost of these stop-gap measures is high; in the current climate of surge pricing, temporary nurse staffing can be up to $100/hour, if a healthcare system can find a nurse to hire.
With the additional problem of nursing school graduations being cancelled or postponed across the country, long-term, Gore sees no end in sight to the pricing surge, particularly with the high levels of anxiety faced by nurses currently on the floor.
“You have nurses that are terrified to work. One agency we were talking to yesterday had over 70 cancellations—in 1 week. They expect 100 more by the end of the day. There’s so much concern and anxiety, and nurses don’t feel like they’re being protected. It’s making a bad problem even worse.” The stress of COVID-19 is felt acutely by nurses. Understanding what we are asking of them and providing for the individual will save the lives of nurses and patients.
“If you are going to ask healthcare team members to be not only exceptional medical and clinical operators, but also exceptional human beings, in terms of being compassionate, then we need to offer robust IT support,” Collins says. “Particularly in high-stakes medical situations, this is the only way to avoid cognitive overload, and also burnout.”
Collins points out the importance of understanding, information, and leadership.
“This only works if we all agree that this is going to work,” Collins adds. “We aren’t just solving for getting people the right info in the right format at the right time. We are solving for easing the pressure of making difficult personal and caregiving decisions.”
As nurses make difficult decisions, they should be supported with the best IT possible. Technology will not fix everything, but giving nurses the best tools available will save lives.
A message from Mass General Hospital nurses in an ICU dedicated to treating #COVID19 patients. “We all have a part to play in #flatteningthecurve, we are begging you to do yours so we can do ours.”#wcvb
Courtesy: Russell Gallen pic.twitter.com/A96Gr97CTz
— Peter Eliopoulos (@petereliopoulos) March 31, 2020
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