A Glimpse of Nursing in a Pre and Post COVID-19 World

Abstraction

When discussing the current state of nursing two questions must be considered. First, is there a safe nurse-patient ratio? Second, what has been the impact of COVID-19 on the state of nursing so far? Multiple peer-reviewed research articles and credible news articles are examined in order to come to some kind of a conclusion. A meaningful middle ground can be had by allowing nurses to have a direct say in their staffing based on the acuity of patients instead of sweeping generalizations. For the latter question, the mental health of nurses and those willing to continue in this landscape that COVID-19 has created is dwindling. Direct and compassionate action must be taken to heal and it is needed now.

Process and revision Summary

                      I wanted to write a portfolio advocating on behalf of a demographic whose well-being effects not only me but society as a whole. I chose nursing because very recently I graduated from nursing school and became a registered nurse myself. Inspired by true events that happened to me, I wrote about from the perspective of a floor nurse working part of the Coronavirus-19 pandemic.  With this in mind, I started gathering articles and resources on not only safe nurse patient ratios but what appears to be happening to the field of nursing as a result of the virus as well. The field of nursing, which has been one of my leading passions this past decade, seems to be under threat of utter collapse, despite the best efforts of those courageous nursing. It is not their fault that this virus is winning, it’s a matter of numbers. Too many people are getting sick with the Corona virus, and there are too few nurses to take care of all of these patients. These dire circumstances are utterly exhausting. No amount of meditating can stop someone from burning out. At that point, you have to sit out at least a round or two before stepping back in the ring. Trying to practice while burnt out is asking for trouble for both the nurse and the patients they are taking care of. This leads to so many of us having to step aside, but there is no one to take our place. That being the case, I wanted to give a balanced argument trying to see things from both sides of the table, even ones that disagreed with me, an attempt is made to come to a sort of middle ground of sorts. I took advice from my professor that I should try not to be completely negative, since the audience I’m trying to reach is already burnt out enough as it was. My target audience was those directly in the nursing field: administrators, team leaders, charge nurses, floor nurses, and staffing, this is a call to aid from these demographics.

Is there a safe number of patients for one nurse to be responsible for at a time? How has the corona virus impacted nurses and health care providers since it began in 2019? With these two questions in mind, I will present an argument for safer practices and work environments for nurses. First, arguments for and against mandatory nurse staffing will be considered and then an alternative based on patient acuity being the universal agreement among researchers. In asking about the impact of the Corona-19 pandemic on the nursing field, we see how detrimental it has been to the mental health of these healthcare workers, and a look at how the field of nursing is shifting as we speak. What we choose to do now will come to define us for years to come, both the field of nursing and the healthcare system at large.

Though each source had their own unique way of dealing with nurse staffing, they all seemed to agree that an increase in patient acuity requires an increased number of nurses. According to Martin (2015), the research shows a decrease in positive patient outcomes when there is an inadequate number of a nurse staffed. The higher the acuity of the patient the more care they will need. That patient’s nurse is going to need spend a lot more time with them, as efficiently as possible, to make sure that they are well. Less nurses on the floor also means that the nurse will have less time to spend helping other patients. These are unsafe working conditions for both the nurse and the patients they are caring for. Martin goes on to talk about how low staffing levels can make it hard for nurses to be non-malfeasance, by putting them in unsafe circumstances (2015). Too many highly acute patients for one nurse can force them to take greater risks, putting the safety of patient at risk. Missed or late antibiotics and other time sensitive medications, delays in rapid response, nurse burnout are all avoidable contributors to patient harm. Martin goes on to talk about how this can be prevented by enacting laws that support these nurses. The studies saw low staffing led to more frequent poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections related to low patient staffing (2015).  These are all avoidable by having the appropriate staffing done based on the acutity and experience of the nurses on that floor.

        However, Martin goes on to warn that we must be careful that the increase in licensed registered nurses and decrease in unlicensed staff could unbalance their essential duties and that here needs to be a national change to solve the problem (2015).  The increase will be effective because an increase of nurses on the bedside increases patient satisfaction, morale, and nurse retention. Ask any nurse on any floor when their best shifts were, and they’ll tell you it was when there were enough nurses working alongside them. That has at least been my first hand experience, and the research seems to agree.  This nurse-patient ratio must be based on patient acuity.

          However, not everyone is in agreement on the matter of mandatory staffing at a national level.  Those experts opposed to mandatory nurse-patient ratios claim that there is no guarantee of improvement in the work environment or patient outcome. This can also be more costly for the hospital. One expert, Welton (2007), wrote that there could be an alternative to mandatory staffing. He claimed that regulating nurse staffing by the cost of care given so that hospitals could be reimbursed for specific skills used. While I agree with Welton on having a more specific patient centered approach to staffing, there are a couple potential drawbacks to this specific method. One is that it will add a level of increased significance to charting accuracy by the nurse. Ideally, your charting will be perfect and done in a timely manner. This would add to an already demanding workload and would take time away from patient care. Furthermore, Welton (2007) points out, patients could deny that nurse-centered patient care was even done.  

All things considered, this method of charging for specific nursing services will show, in a measurable way, what the nurse-patient ratios need to be. It is an idea heading in the right direction. Welton goes on to make one final point: These specific studies should not be used as generalizations (2007). We cannot make sweeping statements for all nurse staff situations or different patients. Some hospitals and patient communities may not need an overarching mandate.  Their needs are different. 

       Tevington (2011) seems to agree that there are positives to increasing the number of nurses.  These include increased patient satisfaction and decreased nurse burnout. However they make it crystal clear that looking only at the numbers for mandatory nurse-patient ratios ignores patient acuity, treatments, length of stay, other staffing dynamics, and physician preference (2011).  Though there needs to be a safe nurse-patient ratio, making sweeping generalizations does not allow for the flexibility needed to set up safe staffing assignments, and does not give a voice to nurses who are on the frontlines.

Tevington and Welton also seem to agree when it comes to funding.  Since there is not funding for these hospitals for the increased number of nurses, they have forced them to get around this in dubious ways (2011).  These include letting go of supporting nursing staff (CNAs, housekeeping etc.) and increasing non patient workloads for RNs (2011). Mandatory ratios take away the nurses ability to advocate for evidence based best practices for nursing as well as patient outcomes

Now with that in mind, on to the second question this essay is trying to answer: How has the corona virus impacted nurses and health care providers since the 2019 pandemic began?  The experts seem to agree: the repercussions that COVID-19 is having on the medical field is that the mental health of health care workers and providers has taken a major hit in this post-COVID world. Demir and Havlioglu, two clinical experts, were able to conduct a study during the first wave of the COVID-19 pandemic. This study showed that the pandemic has brought with it a level of stress including feelings of isolation, anxiety, depression at what seem to be insurmountable circumstances (2020). It is even worse if they have a pre-existing mental illness, now having to add the fear of spreading the virus to family members as well. Another huge take away from this is that when health care providers can trust their leaders to lead by example, provide the needed protective equipment and testing, and feel as though they themselves were treated with compassion, noticed significant improvement to wellbeing (Demir & Havlioglu 2020). Providing this will have to become a bare minimum if we are to ensure the survival of the nursing profession, and the health care system, as we know it.

A further look at the literature appears to indicate this to be the case as well. Bhalnagar et al.  point to the increased fear and stress of acquiring the infection, and nature of transmission with an increased fear due to the virus still being contagious while they are asymptomatic (2020). Bhalgnagar et al. seem to agree with Demir and Havlioglu that “the concerns range from fear of acquiring infection, inadequate personal protective equipments(PPEs), feeling of inadequately supported at work, and worrying about the transmission of infection to peers and family members (2020).” Bhalgnagar et al. take it a step further and suggested ways to boost morale and well-being for healthcare workers working under COVID conditions:

To increase the motivation of health care working in COVID designated areas, the institute should ensure: Basic needs such as food, housing and transportation. A team approach should be made where the leader shows compassion, guides, and appreciates the health care worker. Ensuring adequate availability of good quality personal protective equipment (PPEs). To have a dedicated psychological intervention team for those who have a tough time with poor coping skills. Temperature monitoring and testing for health care workers.

     All of the suggestions made by Bhalgnagar et al. may not be realistically viable for an individual hospital, like a separate recreational area for staff and financial aid for paid workers, but the ones  quoted directly above are. These need to be the bare minimum if we are to have any positive outcomes by the time we’re through with this pandemic.

            Bichell and Hawryluk point to the story of one nurse in particular as a sign of the times for the nursing field at large. It is the story of a nurse working their dream job, satisfied with what they are doing; and then the virus strikes and poor working conditions follow, such as for the absolute necessities such as personal protective equipment, and high patient low nursing ratios led to such high stress levels that make the working conditions intolerable (2020). This has led to a mass exodus of nurses leaving their current job to move on to become travel nurses who are able to have a direct say in their contracts with the hospitals employing them that guarantees them the protection they need (Bichell, R.E. and Hawryluk, R. 2020). 

While I wholeheartedly support my fellow nurses being paid and guaranteed the protection they need, this method of doing so leads to yet another Wild West approach for the hospital, and by extension the health care system itself. Instead of there being a resource-war over personal protective equipment and testing, now it is over nurses. These nurses from around the United States are being paid extremely well by the hospitals they travel to, some to the tune of as much as 8-10,000 dollars per week (Bichell R.E., and Hawryluk, R. 2020). It must be noted that these are only the hospitals that can afford it. This forces the hospitals that are not so affluent less likely to afford the nursing they need, compounded with the struggle these hospitals were already dealing with prior to the pandemic (Bichell R.E., and Hawryluk, R. 2020). Things have even gotten so abhorrent that elected state governors are telling nurses to stay on the job even if you test positive for Covid-19, putting even more patients at risk by spreading the virus further (Bichell R.E., and Hawryluk, R. 2020). People would rather walk or retire earlier from the profession all together than to be treated in such a manner. If we do not want for the face and future of nursing to change beyond our control, action must be taken now. We cannot allow greed to determine our course of action. Extenuating circumstances seem to require that we, perhaps for the first time, put the well-being of nurses first for the betterment and safety of the patient, instead of allowing only the affluent with the means to afford and hire what small number of nurses there are while the pandemic only gets worse. We must go forth with compassion first and foremost, if we are to get through to the other side. Another major point that the NBC news article and other sources (cited previously in this essay) pointed to was the impact that this pandemic is having on the individual nurse. Losing patients to the virus, the risk of becoming infected yourself, and now if you are a travel nurse, may have to pay for your own medical care as well as any therapy that may be needed (Bichell R.E., and Hawryluk, R. 2020). These circumstances are both unacceptable and unsustainable. This eat or be eaten mentality will only lead to a depletion of our resources before we’ve even built the shelter necessary to withstand the storm.

 By asking two questions, important realizations about the field of nursing were to be had. When asked whether there is a safe number of patients for one nurse to care for at a time, experts agreed that more acute the patients are, the more nurses should be on the floor which leads to better patient outcomes. However, they disagreed on the method of deciding nurse-patient ratios, whether they should be mandatory numbers across the board or based on something more.  A middle ground seems to support advocating for a system that allows nurses to have a direct say in their staffing based on the acuity of patients instead of sweeping generalizations. When asked about the impact that the COVID-19 virus has had on the field of nursing and the health care at large, the universal response seems to be that the mental health of nurses and other members of the health care team is greatly declining leading to anxiety, isolation, and burnout. This has led to a nursing shortage, giving those who choose to become travel nurses a direct say in their contracts and are being paid exceptionally well, but the pool of Registered Nurses are dwindling by the day. What we choose to do in our immediate present will define the nursing field for decades to come. If we want retain any resemblance of the profession of nursing and the medical field at large, we must do everything we can to support our nurses, by giving them the resources so desperately needed to fight this worsening and ongoing storm.

~Taiken, George Pearson

Work Cited

Bhalnagar, S.,Bhopale, S., Choudhary, N., Kumar, Haokip, Ratre, Bhatnagar, S., Riniki S., Puneet, R., Nandan, C., Neha, S., Shweta, B., Pandit, A., Ratre B. K., (2020, June 2). Concerns of Health‑care Professionals Managing COVID Patients under Institutional Isolation during COVID‑19 Pandemic in India: A Descriptive Cross‑sectional Study. Indian Journal of Palliative Care. DOI:  10.4103/IJPC.IJPC_172_20

Bichel, R.E., Hawrkluk, M. (2020, November 24). NBC News.  Retrieved from https://www.nbcnews.com/health/health-news/need-covid-nurse-ll-be-8-000-week-n1248652?cid=sm_npd_nn_fb_ma&fbclid=IwAR1QucePlQ3ONr0xQwkRpiqUkbWzfhCfOFuM9cPvbMwZJTSkofuB94gMJB0

Demir, H.A., Havlioglu, S., (2020, April 1). Determining the Anxiety Levels of Emergency Service Employees’ Working During The COVID19 Pandemic. Journal of Harran University Medical Faculty. Doi:10.35440/hutfd.752467 

Martin, C.J., (2015, April 30). The effects of nurse staffing on quality of care. Medsurg Nursing, 4-6. Retrieved from Ebsco Host: CINHAL Plus. 

Tevington, P. Mandatory Nurse-Patient Ratios (2011). Professional Issues. Mandatory Nurse-Patient Ratios. MEDSURG Nursing, 20(5), 265–268. Retrieved from Ebsco Host: CINHAL Plus.

Welton, J., (September 30, 2007) “Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach”OJIN: The Online Journal of Issues in Nursing. Vol. 12. Retrieved from Ebsco Host: CINHAL Plus.

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