Health Progress - Fall 2020

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS www.chausa.org

FALL 2020

Lead theWay

COMING SOON

CATHOLIC HEALTH ASSOCIATION’S

2020 Advent Reflection series is coming soon!

This year, we’ll be offering a reflection and short video for every single day of Advent, plus Christmas Day. We’ll also have a downloadable coloring sheet for children.

Stay tuned to CHAUSA.ORG/ADVENT for this annual complimentary set of resources.

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FEATURES

NURSES LEAD THE WAY

44 TWO ZIP CODES: A WORLD APART SALLY J. ALTMAN, MPH 51 A PATH TO RENEWAL IN WORK AND LEADERSHIP TIM MORAN 57 PROVIDENCE HOLY CROSS OUTLINES STEPS FOR ETHICAL DISTRIBUTION OF A COVID MEDICATION D. W. DONOVAN, D.Bioethics, and REX HOFFMAN, MD, MBA

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 62 MISSION Reimagining Our Ministry DENNIS GONZALES, PhD 64 COMMUNITY BENEFIT Community Health Needs Assessments During COVID Not Mission Impossible JULIE TROCCHIO, BSN, MS 66 POLICY Medicare’s Regulatory Reponse to the COVID-19 Crisis KATA KERTESZ, JD 71 ETHICS Lessons From Smallpox BRIAN M. KANE, PhD Illustrations by Katarzyna Bogdańska

74 THINKING GLOBALLY The Guiding Principles BRUCE COMPTON Humility CAMILLE GRIPPON

4 CATHOLIC HEALTH, NURSING AND ME Julie Trocchio, BSN, MS 7 NURSE COMPASSION FATIGUE Camille Wendekier, PhD, CNE and Kristyn Kegerreis, BSN, RN

77 AGE FRIENDLY Aging Well at Home Through the CAPABLE Program ALICE F. BONNER, PhD, RN, FAAN and SARAH L. SZANTON, PhD, ANP, FAAN

12 RESHAPING THE FUTURE OF NURSING EDUCATION Sr. Rosemary Donley, SC, PhD, ARPN, FAAN 20 COURAGE TO CARE Laura McKinnis, MSN, NP-C 26 NURSES IN EXECUTIVE PRACTICE: A SPECIALTY FOR TODAY AND TOMORROW Kathleen Sanford, DBA, RN, FACHE, FAAN

19 POPE FRANCIS — FINDING GOD IN DAILY LIFE 80 PRAYER SERVICE

33 WOUNDED HEALERS: BEARERS OF HOPE AND HEALING Brother Ignatius Perkins, OP, RN, PhD 37 ACHIEVING AGE-FRIENDLY CARE FOR OLDER ADULTS WITH THE NICHE PROGRAM Jennifer Pettis, MS, RN 41 REFLECTION: WALK QUICKLY, TOUCH GENTLY Janene Papendick, RN, MA

IN YOUR NEXT ISSUE

CARING FOR SENIORS

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EDITOR’S NOTE

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n this strange, world-changing year, I have had more to do with nurses than ever before.

Several people in my family had big health crises in the wrong year to have them. We met nurses who worked in ORs, ERs and ICUs, but also nurse practitioners, mental health nurses, nursing case workers and home health nurses who continue with us along the long and uncertain paths to recovery. Some I’ll remember for a long time, others I never got to know their names. To a person, they have been highly skilled, kind, innovative, patient, tenacious, knowledgeable, gentle, clear and truthful about information that must have been hard to deliver.

One hospital we frequented had posters in the elevators with illustrations of superhero clinicians whose ripped physiques and muscle-hugging outfits touted them as health care heroes.

Another had wall signs noting that their hospital had earned the MARY ANN highest rating for nursing care.

STEINER If it came down to a choice, I’d pick a nurse over a hero any day.

Scrubs can’t compare with flashy, form-fitting costumes, but I see heroes as loners who swoop in and swish out. Nurses, on the other hand, exercise consummate teamwork and are renowned for the constancy of their compassionate care. It’s the reason they belong to the most trusted profession in this country for 18 years running.

With that sort of reputation, you’d think that nurses would have one of the most credible and sought-after voices in health care. That’s not always the case. The authors in our special section — every one of them a nurse — have important suggestions for how the current nursing workforce can deal with the stresses of COVID and the volatile health care environment, and especially how nurses of the future need to be prepared beyond current medical models and business plans.

In the following pages nurses are very concerned about the overall safety and well-being of their colleagues suffering from compassion fatigue, moral distress and grief, as well as coping with insufficient resources and inadequate training for pandemic situations. And with eyes on the future they are reimagining the education of future nurses with strong recommendations for how nursing schools can reformulate curricula in alignment with social determinants of health. They remind us that nurses at executive levels bring an unmatched perspective of clinical,

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administrative and operational excellence.

CHA joins the World Health Organization in recognizing 2020 as the International Year of the Nurse and the Midwife. We are especially pleased that Julie Trocchio, CHA’s resident nurse and champion of aging services and community benefit, celebrates the particular contributions of the nurses of Catholic health care in her introduction to this magazine.

As Health Progress moves into its new quarterly format, we will regularly feature articles that emphasize three topics critical to Catholic health care right now: confronting racial inequities and disparities of care; how the ministry is activating its own transformation within the health care environment; and ongoing dialogue about COVID and its effects. The three features related to those subjects are “Two Zip Codes: A World Apart,” which explores the disparities of health and resources in two St. Louis-area neighborhoods; a look at reimagined approaches to formation and leadership in “A Path to Renewal in Work and Leadership”; and a discussion of one hospital’s discernment about distributing a limited quantity of a COVID medication, outlining an ethical approach to a dilemma likely to become more prevalent.

Your next issue of Health Progress won’t arrive until mid-January, and my first inclination was to send you early Christmas and New Year greetings. But in this strange year and within this liminal space in which we find ourselves between the world we knew and the one we’re moving into, Advent greetings are more timely as it is the season for waiting, preparing, braving the unknown, entering the miracle and protecting the gift of hope within us. “But Mary kept all these things, and pondered them in her heart,” wrote St. Luke.

And so do we. Advent Blessings from your friends at Health Progress.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR MARY ANN STEINER masteiner@chausa.org MANAGING EDITOR BETSY TAYLOR btaylor@chausa.org GRAPHIC DESIGNER LES STOCK

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OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress.

2019 AWARDS Catholic Press Association: Magazine of the Year, First Place; Editor of the Year, First Place; Best Special Issue, Third Place and Honorable Mention; Best Regular Column, Second Place; Best Essay, First, Second and Third Place; Best Feature Article, Third Place and Honorable Mention; Best Reporting on Social Justice Issues, Third Place; Best Writing Analysis, First Place; Best Coverage of Immigration, Second Place; Best Coverage of Disasters, Second Place.

Association Media & Publications EXCEL: Best Special Issue, Bronze Produced in USA. Health Progress ISSN 0882-1577. Fall 2020 (Vol. 101, No. 4).

Copyright © by The Catholic Health Association of the United States. Published bimonthly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29; foreign, $29; single copies, $10.

POSTMASTER: Send address changes to Health Progress, The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797.

EDITORIAL ADVISORY COMMITTEE Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Michigan Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

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Catholic Health, Nursing and Me JULIE TROCCHIO, BSN, MS

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his is a story of a personal journey. Because I’m a nurse by profession and have worked at the Catholic Health Association for decades, it may be surprising that it wasn’t until I joined the CHA that I found out the organization was, and is, much more than health care. It was during my first week at CHA when I attended the board meeting that I encountered the primary issue of “formation,” a term I did not know in relation to health care. Formation, I learned, meant continuing the mission, values and spirit of the sisters who founded — another concept I did not know in this context — our ministries — yet another expression I had to learn, meaning our buildings and services — to continue the healing ministry of Jesus. The discussion centered on the courageous women who left their European convents to deliver nursing care in this country.

What? Many of CHA’s member hospitals and nursing homes were started by nurses? I was a Catholic nurse and went to a Catholic-sponsored school of nursing. Was it true that my new organization was largely started by nurses who were compelled by their faith to care for the sick and injured in this country?

Well, yes and no. They were nurses, but also teachers and administrators and social workers and sometimes carpenters and plumbers.

This began my love affair with the nurses who have shaped Catholic health care. There was much to learn.

Suzy Farren, then the editor of CHA’s newspaper Catholic Health World, wrote an oral history years ago about aging sisters, A Divine Romance.

There were beautiful stories about nurses who worked long hours under difficult conditions: nurses sent to mother superior to be told the order needed dieticians, so they signed up for nutrition classes and left nursing behind. (Although nurses like to say, “once a nurse, always a nurse.”)

There were stories about nurse administrators who integrated the first hospitals. There were sister nurses demonstrating for civil rights at Selma,

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Alabama, on the bridge with the late John Lewis and Martin Luther King Jr. in 1965.

The then-chief nurse at Catholic Health Initiatives, Kathy Sanford, introduced me to Mother Catherine McAuley’s Careful Nursing, a philosophy of compassionate and holistic patient care, brought to the Crimea by the Irish nurses taught

by McAuley. It became part of Florence Nightingale’s nursing reforms.

I read John Fialka’s Sisters with stories about nurses who were gutsy, defiant, passionate and addressed the social determinants of health long before the Centers for Disease Control and Prevention started using the words. He wrote about the Sisters of Mercy. Trained by their order’s foundress McAuley, they came to Pittsburgh, New York, San Francisco and other parts of the country. They took care of the sick in poorhouses, penitentiaries and wherever they were needed and eventually started what would become Catholic hospitals throughout the United States.

A Call to Care, another Suzy Farren product, taught me about the history of nursing nuns, starting in New Orleans in 1727. The book told of Mother Marianne Cope, who brought cleanliness

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and order to the leper colony in Molokai, Hawaii.

She also nursed Father Damien as he was dying of leprosy. Both are now recognized as saints for the brave care they provided. There are so many other examples. I read about Rose Hawthorne Lanthrop, who after taking a short course in a New York Hospital, nursed poor women who were dying of cancer. There were sisters who nursed the injured and dying in the Spanish-American War and in the Civil War. Then I met the modern-day nurses of Catholic health care: When I first knew of Sr. Rosemary Donley, SC, PhD, she was president of the National League for Nursing, the organization that supports nurse educators in many ways. What a delight to find her on CHA’s board, where she advocated for nursing, vulnerable people and quality. She now holds an endowed chair at Duquesne University in Pittsburgh where she teaches nursing students

is a human “Nursing response to human

needs for protection, assistance and consolation during times of sickness, injury, suffering and impending death. The impetus to be a nurse has its source in the spiritual dimension of the person and is associated with fulfilling a perceived purpose in life. Nursing can be a way of sharing in the Supreme Being’s love for humanity through being available to act as a healing instrument.”

From: Careful Nursing: A Model for Contemporary Nursing Practice Therese Connell Meehan BSN, PhD

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about the needs of vulnerable patients and other people.

Then I met Ann Hendrich, PhD, who recently retired as senior vice president and chief quality/ safety and nursing officer at Ascension Health.

To her, excellence in nursing meant establishing the evidence base for quality, and she led research on preventing ICU infections, improving maternity outcomes and more. She also spearheaded the nationwide effort to make health care systems more age-friendly.

Kathy Sanford, mentioned earlier, was another nurse who believed in improving nursing knowledge. One of her first acts as chief nurse at Catholic Health Initiatives was to establish a department on nursing research. She also authored a regular column in the Healthcare Financial Management Association journal on the interface of patient care and hospital finances.

Cherie Sammis and I became great friends. She was a nurse practitioner who had learned about the horrors of human trafficking. Realizing that some patients she had previously cared for were probably victims of this modern-day form of slavery, she embarked on a mission to teach other nurses and caregivers how to identify and treat such trafficked victims.

And then I met Sister Carol. Fueled by a passion for the poor and anchored by the nursing process, Sr. Carol Keehan, DC, served as a maternal/ child floor nurse, head nurse, director of nursing, hospital administrator, board member for hospitals and universities, and association president.

In between, she was a quality consultant to Japanese nurses, helped establish hospitals in two countries, and is the chief pit master in her Maryland home with other Daughters of Charity. She has pens from the signing of the Affordable Care Act given to her by President Obama and House Speaker Pelosi for her tireless efforts to pass the ACA, and yet she always had time for her colleagues, whether they had a struggling child or a cancer scare. She, like so many of CHA’s nurses, was both remarkably capable and remarkably caring.

I keep reading about the early nurses and keep meeting new leaders. And I am never disappointed.

JULIE TROCCHIO is CHA’s senior director of community benefit and continuing care at the Catholic Health Association, Washington, D.C.

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Nurse Compassion Fatigue

An Unintended Consequence of the COVID-19 Pandemic

CAMILLE WENDEKIER, PhD, CNE and KRISTYN KEGERREIS, BSN, RN

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he COVID-19 pandemic has catalyzed many changes in the delivery of health care.

These changes range from time-intensive infection control routines to family visitation restrictions for patients admitted to acute health care facilitates. While these changes aim to protect patients and health care workers from contracting COVID-19, these new protocols have unforeseen ramifications on registered nurses.

In particular, nurses need to focus on pre- Consequently, the RN may not be able to astutely venting medical complications associated with identify significant changes in a patient’s behavCOVID-19, which may cause them to question ior. Patient care issues, which we will delineate their ability to compassionately provide holistic in the following paragraphs, can impact the art care to the patient. As a result, nurses caring for of nursing and increase the risk of compassion COVID-19 patients are at high risk for experienc- fatigue for nurses working with patients on a deding compassion fatigue. Compassion fatigue is the icated COVID-19 unit. We’ll conclude by discussphysical and mental exhaustion and emotional ing ways to prevent compassion fatigue. withdrawal experienced by those caring for sick or traumatized people over an extended period RAMIFICATIONS OF NEW COVID-19 PROTOCOLS of time. Compassion fatigue differs from burn- The many COVID-19 infection control and patient out in that it results from emotional agony rather assessment protocols can be very tedious to folthan daily administrative stressors. Compassion low. For example, nurses adhere to strict infection fatigue can impact the art of nursing as it is prac- control protocols to protect their patients, themticed by an individual nurse. selves and their families from becoming infected Barbara A. Carper’s Fundamental Patterns with COVID-19. Time taken to don and doff perof Knowing is often associated with the art of sonal protective equipment (PPE) can take time nursing. These patterns consist of empirics (the science of nursing, eviThe moral anguish that leads to dence-based practice); ethics (moral nurse desensitization in compassion obligations); personal knowledge in nursing (authenticity in interperfatigue can impact the nurse’s ability sonal relationships); and aesthetics (knowing what is significant in to establish authentic relationships a patient’s behavior.)1 Compassion with COVID-19 patients. fatigue has a direct impact on personal knowing, aesthetic knowing and ethical knowing patterns. The moral anguish away from the patient’s bedside. Diminished time that leads to nurse desensitization in compassion at the bedside could cause fears of missing an fatigue can impact the nurse’s ability to establish acute change in the patient’s condition that would authentic relationships with COVID-19 patients. lead to a life-threatening event.

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Additional changes in the delivery of care to CHANGES IN FAMILY VISITATION POLICIES COVID-19 patients include the “clustering of care” Many hospitals limit the number of patient visiwhere nurses plan the delivery of care so that tors or began to prohibit visitation completely they can minimize their time in and trips to the during the pandemic. This is a necessary measure patient’s room. While the intent of clustered care to limit COVID-19 exposure to hospital employis to minimize exposure to the virus, this practice ees, patients and visitors. However, the change also diminishes the time spent with the patient. As in visitation policies creates frustration in fama result, nurses experience difficulty in develop- ily members and significant others because they ing authentic relationships with the patients that cannot be with their loved one and witness their would allow them to identify significant changes loved one’s response to the COVID-19 infection. in behavior related to spiritual or mental health They experience immense fear about their loved needs. Subsequently, many nurses worry that they one’s ability to recover from COVID-19 and often are not providing adequate individualized holistic feel as though their loved one is the only person attention to their patients that could result in the going through this experience. These feelings neglect of spiritual and/or mental health needs. are heightened by media reports that may senThis situation can cause frustrating mental con- sationalize the illness. As a result, family memflicts where the RNs worry about their ability to bers and significant others often become angry attend to physical versus spiritual needs of their when denied visitation privileges. Due to the lack patients. The continued exasperation in facing of sound protocols or systems for maintaining this emotional struggle on a daily basis can result transparency in patient care to loved ones, family in feelings of defeat and desensitize the ability to members may call and take out their frustrations feel compassion when delivering care. on the nurses. These frustrations felt by family Delays in the delivery of care also contrib- members have led some of them to make threatute to the mental exhaustion nurses experience ening calls to nurses in response to limited or when caring for patients infected with COVID- prohibited visitation policies, face mask require19. For example, many hospitals prohibit keeping ments, or the critical condition of their loved one. care supplies in patient rooms to minimize crossAlthough nurses do their best to educate famcontamination of the virus. Nurses need to plan ily during phone conversations, their ability to their patient interventions and ensure that the appropriate care supplies are in The inability to help the family the room. Often, unanticipated situations may cause nurses to need items such as unit can cause an emotional linens, oral care kits or alcohol swabs as conflict for these RNs because they are attending to the patient. In these situations, the nurses delivering care canthey were taught that holistic not leave the room. They are dependent nursing care includes supporting on other nurses to deliver the needed supplies to them and this takes time, especially patients and families. when the unit is understaffed. The resulting frustrations from lack of care supplies can easily cause nurses to need to focus more interact with family is limited by distance and/ on the physical care of the patient to effectively or time. Nurses working on dedicated COVID-19 manage their time. Therefore, the time manage- units have to prioritize their patients’ care over ment frustrations further limit their capability to answering telephone calls. They need to ensure develop authentic relationships with the patients. that patients in severe conditions have the care Delays in care and time management issues may they need to optimize the patients’ health outprohibit nurses from developing authentic rela- comes. The inability to help the family unit can tionships with their patients that further fuels cause an emotional conflict for these RNs because worry regarding their ability to address all of their they were taught that holistic nursing care assigned patients’ personal, spiritual, and/or men- includes supporting patients and families. Nurses tal health needs. experiencing any of these situations can experi-

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ence an array of emotions ranging from anxiety to fear because they cannot practice nursing according to their ethical and professional standards.

The negative turmoil associated with a limited ability to help the family unit places these nurses at a higher risk for compassion fatigue.

LIFE-THREATENING PATIENT EVENTS

Patients hospitalized with COVID-19 infections have many critical health needs. The life-threatening situations these patients experience commonly result in calling a rapid response or code blue. However, rapid response and code blue care can be delayed because the interdisciplinary health team members are unable to go directly into the patient’s room to provide advanced life support. They need to stop in the hall and don the proper PPE prior to entering the patient’s room.

In the meantime, the nurse in the room is doing his or her best to help the patient overcome the life-threatening health complications. The stress of this can cause a nurse to emotionally withdraw as a means of self-preservation.

In addition, the number of response team members may need to be restricted to minimize cross contamination of the virus. Hospital infection control protocols may limit interdisciplinary response teams to one doctor, one respiratory therapist and two RNs. The limited number of response team members may lengthen the time to administer oxygen therapy and medications needed to ideally convert the patient’s critical status to a stable condition. The increased time for responding to and conducting rapid responses or code blues can demoralize a nurse, particularly when the patient does not survive the event.

Working on a dedicated COVID-19 floor is almost a guarantee that the nurse will have at least one rapid response each day they work on the unit. This reality can cause dread and anxiety at home when thinking of or planning to go to work.

Nurses working on COVID-19 units may become preoccupied with worrying about life-threatening events on future work days. This preoccupation could result in detachment from others at work and home. The continued exposure to this anxiety and the apprehensions described earlier could easily overwhelm RNs and set them up for the mental and physical exhaustion associated with compassion fatigue.

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PREVENTION OF COMPASSION FATIGUE

In the midst of the pandemic crisis, it has been very difficult to prevent compassion fatigue in nurses. At the beginning of the pandemic, the scientific community did not know much about the COVID-19 virus. As we learned more about the virus, hospitals adapted their protocols to limit its transmission and to prevent hospital-acquired infections of COVID-19. This was a time of flux and rapidly changing protocols. The unknown coupled with the changing evolution of protocols were enough to generate fear and worry that could lead to compassion fatigue.

Now that the health care community has learned more about the virus and treating infected patients, protocols have been solidified in the treatment of COVID-19 infections and curtailing the transmission of the virus. Although the protocols are not perfect, they are helping improve patient outcomes. Nurses and health care leaders can review the protocols in relation to adverse situations that occur in the implementation of the patient care protocols to identify what antecedents to compassion fatigue can be avoided. For example, there may be ways to safely store common care supplies in patient rooms. This would minimize care interruptions caused by waiting for someone to deliver supplies needed for addressing an unexpected patient event. Another way to minimize care interruptions could include the use of a designated nurse or nursing assistant to act as a “runner” and bring supplies to their coworkers delivering care in patient rooms. The runner nurse or nursing assistant would not have a patient assignment, so would be able to deliver care supplies to patient rooms with little delay.

Additional measures to minimize anxiety and fears in patient families and nursing staff include formal family support services. While it is the hospital’s obligation to prioritize the treatment of the patient, family units often have little formal support. A support system for the family or a patient’s loved ones could be developed and serve to educate the family on COVID-19, transmission of the virus and the care their loved one is receiving. This education would encompass teaching the rationale for increased infection control measures, routinely providing information on the patient’s condition and treatment, and providing the family with contact numbers and names for answering questions or addressing concerns. The director

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of nursing could spearhead the development of this support system by leading an interdisciplinary team with representation from clinical leaders and various hospital departments. Departments such as patient services, pastoral care, infection control, emergency services, admissions and social services could provide different perspectives in family support and education that would help family members from the time the patient is admitted to discharge. Holistic, proactive education may prevent feelings of frustration and anger in the family.

Finally, an emotional support system should be available to the RNs that would help them learn about compassion fatigue and identify ways to prevent it. This support service could be given through existing employee assistance programs.

Counselors in these programs could help nurses learn how to use personal boundaries, coping skills and resiliency skills to prevent compassion fatigue. Nursing administration could also help nurses understand the importance of self-care (for instance, proper sleep, work-life balance) in the prevention of compassion fatigue, and try to adjust schedules that allow for nurses to spend

more quality time with their families. This would help nurses identify ways to increase their ability to engage in activities such as exercise, prayer and/or meditation at home and at work. The improved ability to support the emotional and physical well-being of nurses can help mitigate compassion fatigue and subsequently improve the delivery of quality care to patients diagnosed with COVID-19.

CAMILLE WENDEKIER is an associate professor and the MSN Leadership/Education program director at Saint Francis University in Loretto, Pennsylvania. KRISTYN KEGERREIS is a registered nurse at WellSpan Chambersburg Hospital in Chambersburg, Pennsylvania.

NOTES 1. Barbara A. Carper, “Fundamentals of Patterns of Knowing in Nursing,” Advances in Nursing Science 1, no. 1 (1978): 13–24, https://doi. org/10.1097/00012272-197810000-00004.

2. Emily Peters, “Compassion Fatigue in Nursing: A Concept Analysis,” Nursing Forum 53, no. 4 (2018): 466–80, https://doi.org/10.1111/nuf.12274.

QUESTIONS FOR DISCUSSION Camille Wendekier is a nurse educator and Kristyn Kegerreis is a practicing nurse who has been caring for COVID-19 patients. Together they are concerned with compassion fatigue among nurses dealing with the pandemic and other stressful circumstances that nurses aren’t always prepared to handle. Compassion fatigue is defined as the physical and mental exhaustion experienced by those caring for sick or traumatized people over a long period, often resulting in emotional withdrawal from patients, colleagues and family members.

1. What are the dangers to the nurse, the patient and the relationships among other clinical and professional staff when nurses don’t recognize their own compassion fatigue? What are the signs of compassion fatigue that nurse administrators and colleagues should be able to identify? What measures discussed in the article can help prevent compassion fatigue? What is your system doing to prevent compassion fatigue?

2. Nurses who’ve been trained to uphold holistic care and to support the family members are struggling to carry out what they’ve understood their role and mission to be. As nurses struggle to care for patients under extreme COVID restrictions, what aspects of holistic care may be in danger? What can health care leaders do to support families while protecting nurses who oftentimes find themselves faced with unhappy family members or stressful communications?

3. In addition to supporting nurses on the floor and in the COVID units, what can schools of nursing do to ensure that curriculum better prepares the emerging nurse work force for this and future pandemics? Can you think of ways to improve the relationship between Catholic health ministries and nursing schools to develop more focused training for nurses getting ready to enter practice?

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Lessons from COVID

Reshaping the Future Of Nursing Education SR. ROSEMARY DONLEY, SC, PhD, ARPN, FAAN

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uring the pandemic of 2020, nurses and other health professionals have been praised for their bravery and commitment to the care of their patients. These frontline workers in their identifiable protective uniforms work long hours in hospitals, long-term care facilities, schools, day care centers and community-based clinics. No practicing nurse or physician learned how to care for or treat patients with COVID-19 while in school. They rely on teamwork and the support of colleagues because there are few COVID-19 protocols, rubrics or evidence to guide practice.

How does the appearance and spread of the coronavirus affect patient care, the nursing workforce and nursing education? As health care providers learn more about caring for patients who have the coronavirus, we have to be thinking about the immediate and long-term impact of COVID-19 on students, faculties and the curricula in universities that prepare baccalaureate degree nurses, advanced practice nurses, clinical leaders, administrators, researchers and others.

While this pandemic will end, the virus and others like it are part of our future.

COVID-19 is everywhere. It ignores age, gender, sexual identity, race, religion, occupation, career trajectory, socioeconomic status, political party or geography. We no longer live a linear life because our realities and world have been rearranged. When we recall 2020, we will describe a “lifequake.”1 What have nurses learned during the pandemic that will guide them into the future? The question is timely because most nurses studied and began to practice under a medical model entrenched in American health care and based on the idea that people went to doctors or nurse practitioners to

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be diagnosed and treated. Patients left their providers’ offices knowing the names of their illnesses and armed with treatment plans. Cooperation or compliance with treatment plans may have created difficulties, but there was little ambiguity around the illness that caused their symptoms or their treatment options. Compare this familiar scenario with the symptoms, diagnosis and treatment of COVID-19.

HARD TO PIN DOWN

The coronavirus is as mysterious as it is ubiquitous and contagious. There are no simple or certain symptoms. People with COVID-19 report a wide range of mild to severe symptoms that appear 2-14 days after exposure to the virus and include fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. People who are asymptomatic can spread the virus.

Clinicians ask themselves does my patient, who has tested positive for COVID-19, have a respiratory, cardiac, neurological, renal, vascular,

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or a multi-system disease? Will it be acute or will RESPONDING TO “NOVEL” ILLNESS she or he have lingering symptoms and become Because the virus is novel, doctors and nurses a “long hauler?” Do I need to admit this patient? learn from past clinical experiences, whether Does my patient need an ICU bed or a ventilator? their own or from colleagues or in the literaTesting remains a problem in the United States. ture. No living nurse practiced during the SpanThere are many opinions about when, whom, ish influenza. Some health providers remember where and how we test for COVID-19. Do we test a strange lung infection, Pneumocystis carinii people with symptoms or known exposure? Do pneumonia (PCP) that appeared in five healthy we test asymptomatic people or high-risk groups, gay men in Los Angeles in 1981. In December of persons who are over 65, those in nursing homes, that year, PCP appeared in IV drug users. Around long-term care facilities or prisons, those who are the same time, other young men in California and racial or ethnic minorities, health care providers, first responders, transporTesting remains a problem in the tation workers and those who work in grocery stores? What type of testing United States. There are many are we using? How long does it take to opinions about when, whom, where, learn test results? Delays in reporting facilitate viral spread. and how we test for COVID-19.

Gaps in the testing chain are significant because there are no specific treatments or a vaccine for COVID-19. The medically New York became ill with an aggressive cancer, oriented disease model is inadequate in guiding Kaposi sarcoma. By the end of 1981, there were 270 the practice of health care professionals. Lacking reported cases of what was described as a severe timely diagnostic data and treatment options, sci- immune deficiency and 121 gay men had died of entists, virologists, the Centers for Disease Con- the disease.3 trol and Prevention, and state and federal govI recall the early days, when bedside nurses ernments study the virus, compare global and and other providers did not know their patients’ national studies, invest in vaccine development, HIV status. No record of test results appeared on or purchase and distribute ventilators and pro- medical records. Universal precautions were nortective equipment. Scientists and public health mative for all patients because the exact mechofficials recommend wearing masks, social dis- anism of disease transmission was unknown. tancing, hand washing, and avoiding crowds and Nurses wore gloves and were told to assume that crowded places. They tell people over age 50, every patient was HIV positive. They carefully those with compromised immune systems and observed the appearance of patients admitted to people with chronic diseases to stay at home. medical units and also witnessed the behaviors of Another indicator of how the virus has mystified the admitting physicians. It was a very unsettling the experts is seen in the multiple revisions to the time.

CDC’s recommendations about COVID-19.

My most frightening memory occurred when I was a dean of nursing. Early in 1982, one of our junior nursing students accidentally pierced her CARE PROVIDERS AT RISK The Kaiser Family Foundation, which has been finger with a needle that had been used in a spinal tracking COVID-19 infections in U.S. health care puncture. The resident physician, who performed workers, estimates that 1,226 health care work- the lumbar puncture, had left the equipment on ers had died from the virus into September, 74 of the patient’s bed. No one knew that the spinal tap whom were nurses. An outsized proportion of needle was in the bed sheets. The patient later those who have died were born outside the United tested positive for HIV/AIDs, which was then a States, many from the Philippines. A study by Kai- fatal disease. By September 1983, the CDC identiser Health News and The Guardian called “Lost on fied the major routes of spread, ruling out transthe Frontline,” profiled 209 health care workers mission by casual contact, food, water, air or surwho have died in the line of duty. Many of those faces. At the end of 1983, the CDC published its care providers died during April, 2020, and had first set of recommended precautions for health care workers to prevent AIDS transmission. By lived in New York or New Jersey.2

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then, the number of AIDS cases in the USA had risen to 3,064 and 1,292 people had died.4.

Our student was the first subject to be enrolled in an National Institutes of Health study of exposed health care workers. Tested throughout her academic program and followed by NIH researchers during her early years in practice, she never tested positive. There is still no vaccine for HIV/AIDS, but retroviral treatments have enabled people to live. Thirty-four million people are living with HIV/AIDS globally, which is considered as a chronic disease. The HIV/AIDs epidemic highlighted the vulnerability of nurses and other health care providers.

Six months into the COVID-19 pandemic, the virus is still “novel.” While we know its primary mode of transmission, the science is undeveloped.

Lacking treatment or a vaccine, public health authorities emphasize testing and isolation of persons who have tested positive and those awaiting test results. However, there is disagreement between public health experts and those who wish to limit testing. Testing has been politicized because of the epidemic’s impact on the economy and the November election.

Briefings from the Coronavirus Task Force are infrequent. Nevertheless, daily and often conflicting advice comes from the White House, the CDC, other federal agencies, the governors and the media. The CDC changes its recommendations without explanations. The lack of transparency and clarity makes people question whether preventive strategies are worth the inconvenience and effort. Trust is eroded.

CHANGE TO MEET STUDENTS’ NEEDS

For decades, curriculum theorists like Ralph Tyler have said that the objectives as well as instructional and evaluation strategies that characterize the curriculum flow from the needs of students, the needs of society, and what subject specialists say is important in the discipline.5 Today and in the future, nurses, students of nursing and faculty need an in-depth understanding of public health nursing and the epidemiology of infectious diseases. Faculty need to reinvest in public health nursing and expand their knowledge beyond the communicable diseases of childhood, immunization schedules, and reviews of the health promotion and treatment components of the Affordable Care Act of 2010 or the Ryan-White Comprehensive AIDS Resources Emergency Care Act of 1990.

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The eradication of smallpox in Somalia in 1979 gave false assurance that epidemics were in the past. The American health care system felt secure in its ability to manage infectious disease and became complacent. Hospitals, the major employers of professional nurses, invested in high technology medicine and focused on enhancing their diagnostic and treatment capabilities. 6 Health providers and health systems relied more on antibiotics than on sanitation to limit the spread of hospital-acquired infections. Nursing school curricula, state licensing and professional certification examinations followed the medical model’s emphasis on the diagnosis, treatment and care of seriously ill people in acute care hospitals.

Faculty and schools of nursing emphasized care of sick people and acute care practice. Faculty decisions significantly reduced the number of graduate programs in public health nursing and limited undergraduate courses and clinical experiences in public health. The CDC and state public health departments suffered budget cuts and lost staff. Local public health agencies outsourced programs to the private sector. It became increasingly difficult to find a position in public health.

When nursing’s professional associations adopted their LACE (licensure, accreditation, certification and education) document, they excluded public health nurses in their classification of advanced practice nurses.7

A POST-PANDEMIC PLAN OF STUDY

The public health component of nursing curricula needs re-examination and innovative change.

Undergraduate students need to re-engage in clinical immersion within communities and focus on population health. While the medical model addresses care of very sick individuals, public health speaks to prevention and emphasizes factors that influence population health and wellbeing over a lifetime. Public health promotes personal and communal behavior that enhances wellness. Simulation scenarios and case studies offer creative opportunities to teach and practice precautionary behaviors specific to the bacteria or viruses’ mode of transmission. Students need to practice the selection of appropriate isolation procedures, hand washing and gowning techniques.

Population health received increased attention when health determinants became the building blocks of Healthy People 2000. The following

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graphic expresses the health determinants identified in Healthy People 2020 that differ from those identified 20 years ago in Healthy People 2000.8

In 2020, the Centers for Disease Control and Prevention named five influences on health: neighborhood and the built environment; economic stability; education; social and community context; and health and health care. Healthy People 2020 provides a compressive framework to guide the public health nursing curriculum.

FOCUSING ON HEALTH INFLUENCES Neighborhoods and the Built Environment

the city’s largest employers. Although the major work of these institutions is health care and education, they influence the local economy and can be major forces in improving public health.

Driving around neighborhoods is an inexpensive way of carrying out public health community assessments. Faculty and students identify upper-, middle- and lower-class neighborhoods.

They assess built neighborhoods, counting supermarkets, banks, grocery stores, bars and libraries.

They can ask questions about the neighborhood as, how often is the library open and does it have a children’s section? Students can look for trees, gardens, flowers, playgrounds, littered empty lots and broken concrete sidewalks, and count the numbers of single-family homes vs. large apartment complexes. They can visit bookstores, bowling alleys, gas stations, diners and fast-food places and ask residents where they shop or receive health care.

Economic Stability As described above, windshield assessments provide glimpses into the economic stability of local communities. They allow students to compare one community to another. Data enable students to determine the average price of houses and rental apartments. They can note the number and types of cars parked in garages or on streets and check the availability of public transportation and determine if residents work close to home or travel to work. Poverty affects health status and health care outcomes. One major indication of economic stability is turnover in a community.

How often does the neighborhood change? What is the average tenure of residents? Another indi-

The Determinants of Health 2020 describe the qualities of neighborhoods where people live, work and play, identifying zip codes as indicators of economic stability and population health.

Neighborhoods differ around the country and change over time. Some neighborhoods have retained their ethnic, racial and/or religious identities. Many cities have a Chinatown, a Little Italy or a Little Havana. The cultural, ethnic, racial and religious Driving around neighborhoods is an roots of communities affect population health. inexpensive way of carrying out public Some neighborhoods bear health community assessments. marks of their past, witnessing to better times. For example, vacant lots were once the sites of steel mills, cator is the amount of money that states spend haunting symbols of what used to be. Many work- on public health. For example, Pennsylvania, the ers in the old mill and mine towns still suffer from state where I live, spent an average $13 per person diseases they acquired in their former workplaces. on public health in 2019, and ranked 45th in the list Others can only find low-paying jobs in communi- of states and the District of Columbia.9 ties that once were middle class. College towns, Education on the other hand, have more transient populations, and the health of the community reflects the Education is a way out of poverty. It is also an age and behavior of students. In some communi- important indicator of health. When parents are ties, hospitals and academic health centers are educated, the economic life of families improves;

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the educational level of parents is also associated with the academic success of their children. Zip codes are important in evaluating the quality of education in communities. Quality can be measured by student-teacher ratios and the presence of counselors, physical education instructors, music and art teachers and school nurses who run active programs. Students in good schools score higher on standardized tests and have lower absentee and truancy rates. Fewer students in good schools drop out; the majority finish school, enter the job market or enroll in college or trade school. Nursing students can learn what databases report the quality of schools in communities and in the state.

and hunger negatively affect health. Other neighborhoods have been neglected and allowed to deteriorate. When crime and violence mar a community, people are afraid to leave their homes to walk in their neighborhoods.

Health and Health Care Geographical maldistribution of health providers limits access to health care and mental health services especially in rural communities. Although physicians and nurses raised in rural communities are more likely to return home to practice, access to specialists and hospitals remains limited.10 Telehealth helps when there is dependable internet access. Access to primary care providers is the backbone of health care delivery in rural America, where people live far from each other and trips to physicians and hospitals are costly

Social and Community Context What is the health of the people in the community and how do social factors influence population health? Identified facNurses must advocate for a more tors that influence health include age, family structure, work status, living robust public health system at all arrangements and safety. The age of the levels of government. They must be community’s residents is a significant predictor of population health. Ameriat policy tables. cans are aging, and it is not surprising that chronic disease affects 6 out of 10 Americans. Chronic illnesses, which are the lead- and time consuming. Health literacy is especially ing causes of death, cost on average $3.5 trillion important in rural areas because individuals need a year. Chronic illnesses are exaggerated by poor to be informed about their illnesses and treatnutrition, excessive consumption of alcohol, use ment plans and become partners in managing of tobacco and decreased physical activity their health.

Relationships are important; family members and friends positively influence health. CORONAVIRUS — WHAT WE’RE LEARNING How many people in the community live alone What have nurse educators learned in a COVID or are part of a family? How many residents are world? COVID-19 has provided evidence that pansingle parents? What percentage of residents are demics can occur and that global travel and trade employed? What is the average individual and/ make everyone vulnerable. Because faculty want or family income? Are there community centers to prepare nurses to provide quality care to their for early childhood development? Is housing ade- patients, the evidence supports a new approach to quate, affordable and safe? Is the community orga- public health nursing and population health. Facnized and do residents work together to improve ulty need resources, development, administrative the well-being of the community? support and time to reform the curriculum.

The social context of the community is a COVID-19 also opens a new area for nursing public health blueprint. Students of nursing can research, evidence-based practice and scholarly learn from observing local communities, talking investigation. There are gaps in the nursing literato residents and examining data systems. Infec- ture about population health and prevention. Pubtions like the COVID virus affect people where lic health also involves the study of social justice they live and work. Some households are crowded and its impact on practice. Faculty and students and social distancing is difficult if not impossible. need to engage in honest dialogues about their There are still communities in the United States implicit biases and the role that health dispariwhere there is no running water in homes. Some ties, diversity, racial injustice and violence have communities are food deserts. Food insecurity on health and human flourishing. Lastly, nurses

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must advocate for a more robust public health system at all levels of government. They must be at policy tables. Although nurses are receiving accolades for their care of people with COVID -19, they were not the faces of the Coronavirus Task Force or visible leaders in the FDA, Homeland Security, NIH or the CDC. That needs to change.

SR. ROSEMARY DONLEY is a nursing professor and holds the Jacques Laval Chair for Justice for Vulnerable Populations at Duquesne University School of Nursing, Pittsburgh.

NOTES 1. Bruce Feiler, Life Is the Story You Tell Yourself: Mastering Transitions in a Nonlinear Age (New York: Penguin Press, 2020).

2. “Lost on the Frontline,” Staffs of Kaiser Health News and The Guardian, Kaiser Health News website, Aug. 10, 2020, https://khn.org/news/lost-on-the-frontlinehealth-care-worker-death-toll-covid19-coronavirus/; See also Usha Lee McFarling, “Nursing Ranks are Filled with Filipino Americans. The Pandemic Is Taking an Outsized Toll on Them, Stat, April 28, 2020, https:// www.statnews.com/2020/04/28/coronavirus-takingoutsized-toll-on-filipino-american-nurses/.

3. “History of HIV and AIDs Overview,” Avert website:

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https://www.avert.org/professionals/history-hiv-aids/ overview.

4. “History of HIV.” 5. Ralph W. Tyler, Basic Principles of Curriculum and Instruction (Chicago, London: The University of Chicago Press, 2013).

6. “Facts on Nursing,” American Association of Colleges of Nursing, AACN website, April 1, 2019, https:// www.aacnnursing.org/News-Information/Fact-Sheets/ Nursing-Fact-Sheet.

7. Kelly A. Goudreau, “Editorial: LACE, APRN Consensus... and WIIFM (What’s in It for Me)?” Clinical Nurse Specialist: The Journal for Advanced Nursing Practice 25, no. 1 (January 2011), 5-7.

8. Healthy People 2020 website, https://www.healthy people.gov/2020/About-Healthy-People.

9. John L. Micek, “Pennsylvania Ranks 45th in the Nation in Per Capita Public Health Spending, Report,” Wednesday Morning Coffee, Pennsylvania Capital Star, July 24, 2019, https://www.penncapital-star.com/commentary/ pa-ranks-45th-in-the-nation-in-per-capita-publichealth-spending-report-wednesday-morning-coffee/.

10. Meredith B. Rosenthal, Alan Zaslavsky and Joseph P. Newhouse. “The Geographic Distribution of Physicians Revisited,” Health Services Research 40, no. 6 pt. 1 (December 2005): 1931–52. https://doi. org/10.1111/j.1475-6773.2005.00440.x.

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AM113 / Shutterstock.com

Finding God in Daily Life “Nurses have historically played a central role in health care. Every day, in their contact with the sick, they experience the trauma caused by suffering in people’s lives. They are men and women who have chosen to say ‘yes’ to a very special vocation: that of being good Samaritans who are concerned for the life and suffering of others. They are guardians and preservers of life, who, even as they administer necessary treatments, offer courage, hope and trust.”

Pope Francis message to mark International Nurses Day, from Saint John Lateran in Rome, May 12, 2020

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Courage to Care LAURA McKINNIS, MSN, NP-C

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he world seems out of control. We are in a global pandemic, unemployment has not been this high since the 1930s, wars and political rancor make listening to the news a fast track to a panic attack. In the midst of this chaos, I decided to leave my job and open my own health care clinic. Just when I had arrived at a place of confidence and influence in my career, I jumped ship and swam in a new direction.

I have worked in emergency medicine for 20 shot of the waiting room because there were no years. Over the last 10 years, the health care envi- private rooms. I found this unacceptable. The ronment has continuously declined. I could no problem was not because of overwhelming numlonger work within the status quo of our broken bers of sick and injured patients. Instead, it was system. My patients kept telling me about the ter- due to the fact that the balance between profitrifyingly high cost of care. People in need of medi- able elective procedures and unprofitable chronic cal care are worried about the high cost of care or emergency care had shifted. It put an everand surprise bills. Patients often delay seeking increasing stress on an overwhelmed ER. Health care is an important issue for all Amerihelp because of the financial risk they may face.

Of all the scary things happening in our country, cans. It affects every economic class, especially the health care system is one of the worst. I began the middle class and the poor. “Half of U.S. adults thinking of Psalm 139:12, “Even the darkness will say they or a family member put off or skipped not be dark to you; the night will shine like the day, some sort of health care or dental care or relied on for darkness is as light to you.” Is that even true? an alternative treatment in the past year because How can there be light in such times of darkness? How can a little nurse The world seems out of control. practitioner in Wisconsin make any of this better?

We are in a global pandemic, I left emergency medicine because unemployment has not been this high I felt that the care I was able to provide was declining. One of the hospitals I since the 1930s, wars and political worked in continued to make cuts to both supplies and staffing. For examrancor make listening to the news a ple, in one ER shift I simultaneously fast track to a panic attack. managed four unstable patients in the intake hallway of our ER because no beds were available in the main department. I had of the cost,” according to a Kaiser Family Founto tell a patient that she had a subdural hematoma dation article.1 While we have the most advanced (a bleed in the brain) while her bed was parked health care technologies and treatments, these behind a curtain in the hallway of a busy depart- improvements have come at the cost of people’s ment. I had to deliver sensitive news about diag- ability to afford them. According to the Economics noses to patients seated in hallways within ear- of Healthcare, medical costs consume 18% of the

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gross domestic product of the United States.2 This also places a burden on the cost of doing business.

The Kaiser Family Foundation also published statistics stating, “despite the nation’s strong economy and low unemployment, what employers and workers pay toward (health care) premiums continues to rise more quickly than workers’ wages and inflation over time. Since 2009, average family

When limited resources are coupled with a broken reimbursement system, it is almost impossible to make effective change. I wasn’t fighting a person or a company. It was the system that needed correction. premiums have increased 54% and workers’ contribution have increased 71%, several times more quickly than wages, 26%, and inflation, 20%.”3 The possible solutions to these problems have been reviewed and studied endlessly. But all the attention and study has improved the situation precious little. Our predicament is reminiscent of Charles Dickens’ cautionary tale, Bleak House.

Dickens was writing about the legal system of that day, “which so exhausts finances, patience, courage, hope; so overthrows the brain and breaks the heart; that there is not an honourable man among its practitioners who would not give — who does not often give — the warning, ‘Suffer any wrong that can be done you, rather than come here!’” Our health care system has become a similar quagmire for many in our country.

I needed to leave. I needed to do something different. But how do you do better than a $3.5 trillion dollar industry? How could one nurse practitioner do any better? What tools did I have to make a difference? Where should I even start?

Stones. I had a sling full of stones.

I wrote letters to department and hospital leaders and peers. They would listen to me but nothing changed. I joined committees to improve patient flow. I sat on an ethics committee to learn how principles of faith and care could be applied to complicated end-of-life situations. I offered

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opinions in committees to improve the clinician experience within our own physician group. I wrote and spoke about clinician burnout and tried to support my clinical staff.

Nothing changed. The giant would not listen.

I felt like young David preparing to meet Goliath. I was naïve in the ways of business and finance. I was unprepared for the complexity of a such a monstrous system. I was unwise, unprepared and weak.

But I had learned how to care. I had been a nurse for seven years and a nurse practitioner for 12. I could not stop seeing the needs of my patients, community and peers. And like David, I had been training in the field for years.

In the book of I Samuel, David explains his training this way, “But David said to Saul, ‘Your servant (David) has been keeping his father’s sheep. When a lion or a bear came and carried off a sheep from the flock, I went after it, struck it and rescued the sheep from its mouth.’”(17:34-35).

Nurses are trained to monitor vital signs, make assessments, watch for indications of worsening disease. I had been training in the field of nursing for two decades. The signs that our system is breaking are everywhere.

David had been fighting things that were big, bad and scary his whole life. Nurses are used to being in the battle as well. We care for the sick and wounded and we jump into situations that can be scary. We face down death every day. The question for me became how to apply the skill of caring to this challenge of improving a failing and complex health care system.

I needed to know who I was fighting. Was it leaders, managers, CEOs, insurance companies, suppliers? I think I have found that it is the overly complex health care system that is the real Goliath. There are no truly bad people that I have encountered on this journey. Everyone seems to be doing their best within a job that often puts unhealthy constraints on their decision making.

When limited resources are coupled with a broken reimbursement system, it is almost impossible to make effective change. I wasn’t fighting a person or a company. It was the system that needed correction.

I started by looking to the business world for solutions. Actually, I tried to leave health care and join the field of sales and marketing. This did not work. It is not my skill set and I could not find spiritual fulfillment in it. I began an MBA pro-

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I needed to know who I was fighting. Was it leaders, managers, CEOs, insurance companies, suppliers? I think I have found that it is the overly complex health care system that is the real Goliath.

to recoup costs lost on Medicare/Medicaid by charging other payers more. This often leads to wildly high prices that are then negotiated down by commercial insurers. However, if you are underinsured or uninsured, you have no leverage to negotiate with the hospital. Many individuals pay the full marked up price and are taken into collections because of extreme medical debt. In fact, health care debt is the leading reason Americans file for bankruptcy. And the complexity goes on and on.

This is where my new journey began. Is there any way to simplify this process? Could I provide health care at a reasonable and transparent rate, provide excellent care and still make a living? I left the familiar hospital and clinic work and am trying something new. I started a company to meet the needs of my community and provide care that is both cost effective and convenient.

It is my vision to improve the community I live in by making health care access more convenient and affordable. I have a few “stones.” These include price transparency, efficiency and the agility of a small business to change with the market. But in the end, it is the foundations of nursing that taught me about community assessment.

Business refers to this as market analysis. Either way, it helps health care practitioners understand what their patients really need and how to provide this care. Unshackled from the way it has always been done, I intend to help.

gram. If money had become the game, I wanted to understand it better. What I learned from business was fascinating. I studied the complexity of health care. I learned about the problem of a pricing system that is not transparent. I learned that insurance both protects individuals and causes costs to rise. Insurance reimbursement rates, especially from Medicare and Medicaid, are often significantly lower than the cost to provide services. This results in hospitals billing patients and insurers much higher than necessary in order to make a profit. This is the pricing game.

The health care system is tremendously difficult to understand. External forces can have a positive or negative effect on the health care market. In the health care industry, insurers or government payors may place positive pressure on providers and hospitals to provide lower cost care where reimbursement is tied to health outcomes.

If the pressure is negative, however, it may actually increase The phrase, “do what you can, with what cost by imposing unnecessary and burdensome regulations you have, where you are” has been my for providers to comply with mantra these days. It is a good way to these measures. Who do these measures benefit? Is it truly approach overwhelming problems. the patient or is it for the benefit of the insurer? Externalities I am hoping to use my nursing skills of listencan complicate the market. There is not a single buyer and seller. There is one, or many, additional ing, assessing and caring to make my corner of the parties seeking value in the transaction between world a little bit better. Only time will tell if this provider/system and patient. The normal market is an effective strategy. The phrase, “do what you safeguards cannot work. And who can afford the can, with what you have, where you are” has been my mantra these days. It is a good way to approach cost of care? Is it a right or a privilege?

One way to begin changing the health care sys- overwhelming problems. So many things in our tem is to require transparency in billing practices. world seem daunting and frightening. It is easy In the book, The Price We Pay, Dr. Marty Makary to become paralyzed, hoping the problems will describes at great length the disparity in hospi- just go away. They won’t. We have to apply our tal billing based on private insurance, Medicare God-given skills to our particular areas of experor private pay.4 It is a system clearly designed tise and influence and find the solutions. My

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strengths have been cultivated for two decades in the trenches of emergency medicine. I have learned from my treasured friends who are doctors and nurses how to find creative solutions to difficult situations. I am hoping that this new way of providing care will make a difference.

“Even the darkness will not be dark to you; the night will shine like the day, for darkness is as light to you.” There is hope in our time. We are not promised ease, wealth or simple solutions. But we do have hope. And we all have an important role to play.

LAURA McKINNIS is a nurse practitioner and owner of Oasis Healthcare in Grafton, Wisconsin.

Oasis Healthcare is a self-pay, flat rate and low cost walk-in clinic serving patients for acute medical needs.

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NOTES 1. Ashley Kirzinger et al., “Data Note: Americans’ Challenges with Health Care Costs,” Kaiser Family Foundation, June 11, 2019, https://www.kff.org/ health-costs/issue-brief/data-note-americanschallenges-health-care-costs/.

2. Economics of Healthcare, 2017, https://scholar.harvard.edu/files/mankiw/files/economics_of_healthcare. pdf.

3. “Benchmark Employer Survey Finds Average Family Premiums Now Top $20,000,” Kaiser Family Foundation, Sept. 25, 2019, https://www.kff.org/health-costs/pressrelease/benchmark-employer-survey-finds-averagefamily-premiums-now-top-20000/.

4. Marty Makary, The Price We Pay: What Broke American Health Care and How to Fix It, (New York: Bloomsbury Publishing, 2019).

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GOVERNANCE ETHICS IN HEALTHCARE ORGANIZATIONS Gerard Magill and Lawrence Prybil Based on empirical studies undertaken with boards of directors and CEOs in the United States, this groundbreaking book develops a new paradigm to provide a structured analysis of governance ethics consistent with clinical, organizational and professional ethics.

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Inquiries: contact, evie.lonsdale22@gmail.com

NURSES

Nurses in Executive Practice: A Specialty For Today and Tomorrow KATHLEEN SANFORD, DBA, RN, FACHE, FAAN

A

bout 35 year ago, I was asked to explain the role of a hospital nurse executive to a group of staff nurses at an in-service class, so they could better understand what nursing administrators did when not making rounds on the units. I brought my inbox — then a literal collection of papers — to a hospital auditorium to show the intricacies of the job. I described a role that included shaping and keeping tabs on patient care, staffing, budgets, productivity, safety and at least a dozen other claims on the time of a nursing executive. As the staff nurses left the room, I heard one of them mutter, “Well that sounds like a boring job!”

I have never thought so.

The challenges of what was then called “nursing services” related to balancing the needs of patients, the community, the staff and the organization. Many of the challenges faced by nurse executives in the mid-1980s remain and have become more complex with new challenges brought by an ever-changing health care environment. What has not changed is that many people in the health care industry don’t have a clear understanding of the nurse executive role or its importance to health care and to nurses themselves. They also don’t realize that management is a nursing specialty.

Modern professional nursing practice has steadily developed since Florence Nightingale and Sr. Mary Clare Moore, RSM, led a group of Sisters of Mercy and other nurses to Scutari to care for British soldiers during the Crimean War. Since that time, nursing education and standards have continued to evolve. As the complexity of health care has increased, the generalist nurses of 150-175 years ago have become specialists. Medical-surgical nurses, pediatric nurses, critical care nurses, behavioral health nurses, perioperative

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nurses, advanced practice nurses and other specialists and subspecialists practice with different training, skills and competencies. Nursing management, with a subspecialty of nursing executive practice, is itself a specialty that has become more sophisticated in recent years.

Several decades ago, it was not uncommon for nurses to be promoted into supervisory positions because of their excellent clinical skills.

Those who progressed through the various levels of nursing management to eventually be named chief nurse executives learned the business of health care on the job. By the time they reached an administrative position, they had a thorough understanding of hospital operations from bedside to executive offices. Today, there is a greater understanding that leading the clinical enterprise requires a specific set of competencies in addition to clinical expertise and on-the-job learning.

Both the American Organization of Nurse Leaders (AONL) and American Nurses Credentialing Center (ANCC) offer certifications in nursing management and executive practice. AONL published the first version of their Nurse Executive

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Competencies in 2005 and has refined those over the past 15 years as roles have changed. The competencies include specific actions and abilities under the domains of communications and relationship management, professionalism, knowledge of the health care environment, business skills and principles, and leadership.1 The recognition of nurse executive practice as a specialty has made selection of administrators more dependent on leadership abilities and education rather than on clinical expertise. Nurses pursuing these roles prepare for them through both education and certification. One nursing specialty group, the Association for Leadership Science (ALSN), focuses on nursing administration and leadership programs at undergraduate and graduate levels. Some of us have graduate degrees in management from schools of nursing; some have MBAs from business schools; some have MHAs. A growing number are educated beyond the master’s level, with a Doctorate in Nursing Practice, from an AACN- accredited program (American Association of Colleges of Nursing, which includes the eight essential curricular elements listed in the sidebar below. Those elements correlate to the skills that will be needed if we are to transform our health care systems in

EIGHT ESSENTIAL CURRICULAR ELEMENTS FOR A DOCTOR OF NURSING PRACTICE 1. Scientific Underpinnings for Practice 2. Organizational and Systems Leadership for Quality Improvement and Systems Thinking 3. C linical Scholarship and Analytical Methods for Evidence-Based Practice 4. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare 5. Healthcare Policy for Advocacy in Healthcare 6. I nterprofessional Collaboration for Improving Patient and Population Health Outcomes 7. Clinical Prevention and Population Health for Improving the Nation’s Health 8. Advanced Nursing Practice From The Essentials of Doctoral Education for Advanced Nursing Practice, American Association of Colleges of Nursing, October 2006.

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order to provide higher quality, equitable care.

The nurse executives who lead in health care organizations have different titles and a variety of responsibilities. Depending on the structure of their organization’s executive teams, they may be vice presidents, senior vice presidents, executive vice presidents, or senior executive vice presidents. Some have dual roles as chief operating officers. Many serve as the executive level leader for other clinical professionals in addition to nurses.

Some work closely with chief medical officers as dyad leaders of the entire clinical enterprise. Critical access hospitals have nurse executives, as do other individual hospitals, home health agencies, long-term care facilities, outpatient clinics and other health care community services.

The growth of systems in the past decade has led to an additional type of executive, the system chief nurse. In 2015, AONL documented specific competencies related to this role.2 How system CNE roles differ from single organization CNEs can be pointed out in the wording of the separate sets of competencies. For example, while an individual entity nurse executive is expected to adhere to professional associations’ standards of nursing practice, the system CNO is required to hold the entity-based CNOs accountable for patient care standards. Currently, the individual entity nurse executive must ensure compliance with a specific state nurse practice act, while the system leader must maintain knowledge regarding state nurse practice acts in all states where the system has operations.

THE EVOLUTION OF THE CHIEF NURSE

The original “chief nurses” were called hospital superintendents, and they served as the top executives in the majority of acute care institutions until the late 1930s/early 1940s. (This was not true in early academic centers and a few for-profit hospitals, where MDs led (or, in the case of the forprofits, owned) the organizations. Most people are unaware of this history, but Margarete Arndt and Barbara Bigelow have extensively studied and published why and how hospital leadership was transformed in the first half of the 20th century. A few of their articles paint the picture of hospitals facing three major problems almost a hundred years ago: the need to fund new technology; the less-than-ideal relationships with medical staff; and pressure from business owners to address the increasing costs of health care.3, 4, 5 It was less than 100 years ago that hospitals

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transitioned from a nursing leadership model to ing care standards, evidence-based practice and a business model. Hospitals were beginning to be nurse practice acts — wherever nursing is pracperceived as businesses in the first half of the 20th ticed in the organization. This is just one of the century, and the norms of the time dictated that complexities of the modern health care system businesses needed to be administered by business and has resulted in a plethora of dotted lines on men. In 1929, Michael Davis published, Hospital what were once much simpler straight-lined orgaAdministration: A Career — The Need for Trained nizational charts!

There is now widespread understanding that Executives for a Billion Dollar Business, and How They May Be Trained. Five years later, the Uni- CNEs must have a good grasp of both the macroversity of Chicago established the first graduate and micro-economics of health care, manage large program in Hospital Administration, with Davis budgets and share responsibility with their execuas the program leader. In the 1940s, eight other tive peers for the financial health of the organiuniversities offered this degree, with nine more in zation. In the past few years, nurse executives the 1950s, and 15 others in the 1960s. Arndt reports have become more involved in partnering with that when the MHA programs were established, our finance colleagues. This is highlighted in the they admitted virtually no female students. Nurse AONL System CNE competencies under business superintendents, from a female profession, were no longer hired by hospitals Hospitals were beginning to be who wanted educated administrators. perceived as businesses in the Nurse leaders retained the 24- hoursa-day, seven-days-a week operations of first half of the 20th century, and the hospital, reporting to the MHAs who served as the chief executives. the norms of the time dictated The exception to this was in Catholic that businesses needed to be hospitals, where women religious, both sisters with clinical backgrounds and administered by business men. those with administrative experience, continued to hold the top leadership roles.

As late as 1968, nuns or priests served as CEOs of skills, where one of the five financial competen770 of the 796 U.S. Catholic hospitals. However, cies is to “participate in system activities related in 2011, there were only eight of the 636 Catholic to system bond ratings, investing, and attainment hospitals whose top executives were religious, as of operating margins.”

The list of single entity accountabilities for the leadership of these faith-based organizations was regularly being turned over to lay leaders.6 CNEs differs from organization to organization, Today there are none, according to the Catholic but at a minimum it includes either sole or shared executive accountability for the management of Health Association.

The roles of health care leaders, including the nursing enterprise staff; management of qualnurse executives, have continued to change in ity, safety and patient experience; staffing the both Catholic and non-Catholic organizations. nursing care areas 24 hours a day, seven days a It wasn’t that long ago that CNOs were mostly week; reduction of adverse events; adoption of in acute care settings and heavily involved in the evidence-based standards; development of proday-to-day operations of hospitals. Today, nurse cesses and care models; compliance with regulaleaders still have operational responsibilities, tions and applicable laws; cost reduction; clinical but they also have clinical practice accountabil- adoption of new technology, including electronic ity over care in a variety of settings where they health records; and productivity. Some of the tasks do not have the operations responsibility. That taken on by nurse leaders in the past few years distinction can be confusing, but it means that a have been dictated by changes in regulations, leader outside the nursing profession may serve payment systems and technology. Others are simas the operations manager or supervisor of nurses ply the right thing to do in support of our misin a clinic, post-acute facility, or even in a depart- sions and for the various stakeholders we serve. ment inside the hospital. However, the chief nurs- These stakeholders are not silos, and the health ing officer has responsibility and accountability and well-being of one group affects the health and for the practice of nursing — adherence to nurs- well-being of the others. One obvious stakeholder

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is the nursing care team — nurses and those who work with them to provide care. The COVID pandemic of 2020 has underscored the need to ensure their well-being, not only for them as individuals but for the good of the community’s — and the world’s — health.

THE YEAR OF THE NURSE

Early in 2019, the World Health Organization announced that 2020 would be the International Year of the Nurse and Midwife. It was planned around Florence Nightingale’s 200th birthday and the final year of the Nursing Now global campaign to raise the profile and voice of nurses. On the last day of 2019, a cluster of pneumonia cases in Wuhan, China, was reported to WHO. Seven days later, Chinese health officials shared that the affected people were victims of a novel coronavirus that would come to be known as COVID-19. We were not aware that this newly discovered threat to human health would become, almost overnight, a worldwide crisis. As a result, it was less about the Year of the Nurse, and more about the Year of COVID, that placed nurses in the media spotlight.

Frontline nurses have been caring for the pandemic victims, while nurse executives have been supporting them in health care systems that scrambled to get ready and then face the treatment challenges that come with victims of this still mysterious virus. Nurse leaders sat (and still sit) on hospital and community crisis command centers. Many of us have been working with other community organizations to coordinate local care.

We have been advocating for frontline staff, working with teams to secure essential protective supplies, approving novel ideas for using equipment and technology, moving staff and resources to the sites where they were (and are) most needed, and reporting to hospital or system boards and to others on the heroic, hard and exhausting work being done on the frontlines. We have been cheerleaders for our clinical specialty colleagues, not only where staff can hear this, but in the executive suites as well.

Nurse leaders have a uniquely synchronized view of all issues during a crisis. As clinical executives who have experienced leadership of hospital operations around the clock, we have been required to maintain updated knowledge in the operational side of the organization, the business side of health care and current clinical best practice. As nurses, we are part of a culture that understands work arounds that are done in the best

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interest of patients, as well as the realities of moral distress, burnout and compassion fatigue. Part of the nurse executive role in this year of COVID has been to seek resources and plan interventions to support the mental and physical health of the staff.

We also know the difference between nurse specialties. A number of nurse executives have commented that they were surprised at how their non-nurse colleagues reacted to shortages of critical care and ECMO (extracorporeal membrane oxygenation) nurses at a time when other nurses, including clinic nurses, were without work. They thought that the logical solution was to send nurses with different specialties to work in critical care. However, this solution is not as optimal as it may seem. Nurses who are educated, trained and experienced in various specialties are not interchangeable, and a pandemic is not the time to substitute a novice for an expert in any specialty. Knowing this, nurse leaders reacted quickly to develop care models where the specialists needed could be augmented with other nurses who could perform the general nursing duties that all inpatients need, while critical care nurses led teams and gave care that required their expertise.

In some cases, this expertise has been leveraged through technology in the form of virtual nursing.

INTO THE FUTURE

Even though we don’t know when, we do know that this pandemic will come to an end some day.

We still need to get through it, and nurse executives are setting up programs to educate specialists projected to be in greatest demand if surges of infection continue. We are also planning programs for caregivers who may face post-traumatic stress issues and documenting plans (based on recent learnings) for possible future national or international health crises. Of course, nurse executives are not alone in any of this work. Nor will we be alone in transforming our systems “postCOVID.” We will continue to partner with colleagues, communities and patients themselves as we leverage what we have learned to improve our care models for the future. This pandemic has made it even more obvious that no single profession, individual or specialty can accomplish what needs to be done to improve care in our systems.

Nurses are educated and experienced in teamwork, which will be important as we set up new multidisciplinary models in the future.

It is true that the year of COVID has overshadowed the Year of the Nurse and Midwife. It has,

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however, demonstrated again how important the intellect, hands and hearts of this profession are to the health of the world, which was what WHO wanted to highlight in 2020. The organization’s conviction is that there will never be universal coverage until we have more nurses, who will be universally recognized for their contributions to holistic care and wellness. Those nurses will need to practice at the top of their licenses and specialties. The specialty known as executive practice will continue to do our part as the voice of nursing at the executive table: as balancers of stakeholder needs; as educators of health care colleagues and communities about this profession; and as supporters of advanced practice, multidisciplinary team care and all nursing specialties.

KATHLEEN (KATHY) SANFORD is executive senior vice president and chief nursing officer for Chicago-based CommonSpirit Health.

NOTES 1. AONL Nurse Executive Competencies: www.aonl. org>nurse-executive-competencies.

2. System Chief Nurse Executive Competencies: www. aonl.>system-chief-nurse-executive-competencies.

3. Barbara Bigelow and Margarete Arndt, “The More Things Change, The More They Stay the Same,” Health Care Management Review 25, no. 1 (January 2000)1999: 65-72.

4. Margarete Arndt and Barbara Bigelow, “Hospital Administration in the Early 1900s: Visions for the Future and the Reality of Daily Practice,” Journal of Healthcare Management 52, no. 1, (Jan-Feb 2007): 34-45.

5. Margarete Arndt “Education and the Masculinization of Hospital Administration,” Journal of Management History 16, no. 1 (Jan 12, 2010): 75-89.

6. Kevin Sack, “Nuns, a ‘Dying Breed,’ Fade From Leadership Roles at Catholic Hospitals,” The New York Times Aug. 20, 2011, https://www.nytimes.com/2011/08/21/ us/21nuns.

QUESTIONS FOR DISCUSSION Kathy Sanford has been a nurse executive for several decades with Catholic Health Initiatives, now CommonSpirit. Her perspective on the executive nurse role has a unique vantage point in that she has seen the role of executive move from nursing sister to lay businessmen and women in little more than a generation. Her article is concerned with the balance of clinical excellence, executive acumen, administrative skills and a strong commitment to mission.

1. How is the role of executive nurse understood in your ministry? Does it oversee only nursing or other clinical specialties too? In addition to being a voice for clinical excellence, what other practices and decisions within the health system does the nurse executive speak to?

2. How did you feel about the section on pgs. 28-29 in which Sanford describes the transition from a nursing model to a business model? Talk about what you think may have been lost and what may have been gained in that transition. What is the impact on your own ministry?

3. During this time of the pandemic, when all things are being reimagined, what opportunities do you see in reexamining how our ministries are led? What are the implications as we continue to strive for excellence and quality?

4. Sanford notes the confusion caused when hospitals or health systems made deep cuts to some nurses while other nurses were working long and grueling shifts. What do you think of Sanford’s explanation of nurse specialties? Do you think more emphasis on specialties should be given in nursing schools? What suggestions do you have for preparing nurses for the next epidemic or pandemic?

5. Sanford’s reflection on the Year of the Nurse and the Year of COVID is both poignant and ironic: it took a pandemic for the World Health Organization’s goals of recognition and appreciation for nurses to be fully valued. What is your ministry doing to recognize the important contribution of nurses as essential workers and to honor their unique skills and expertise? What is your system doing to help nurses who may be experiencing burnout, compassion fatigue or post-traumatic stress disorder caused by the pandemic? Do you have suggestions for what else it could do?

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JOIN US!

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NURSES

Wounded Healers: Bearers of Hope and Healing BROTHER IGNATIUS PERKINS, OP, RN, PhD

“In our woundedness, we can become a source of life for others.” — Henri Nouwen, 1972 “After this, aware that everything was now finished, in order that the scripture might be fulfilled, Jesus said, ‘I thirst.’ There was a vessel filled with common wine. So they put a sponge soaked in wine on a sprig of hyssop and put it up to his mouth.” — John 19: 28-29

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n our reflection on Jesus’ thirst as he was dying, we are drawn to consider that his thirst is the result of the trauma of the pain of his scourging and the failure of the crowds to offer Jesus the nourishment of healing on his long journey to his crucifixion and death on Calvary. Yet, even in his suffering and death, he brought healing to the world. Jesus is a wounded healer to nurses and all health care personnel in this time of our journey through the coronavirus pandemic.

During these days, we are called to reach out to our colleagues as wounded healers in our midst, who are suffering in any way, to assure them that they are unique and precious in Jesus’ eyes, the very face of compassion and mercy. In our healing ministry to one another, we are often called to bear some of the burdens borne by our colleagues, as well as to those of our patients and their families, and to quench their thirsts. As clinicians, though imperfect and at times vulnerable, we are committed to do all in our power to restore our patients to heath and never abandon them in their journey toward wholeness of life.

We are wounded healers: we enter into the lives of our patients, and too often we are alone with them, as they die from the coronavirus;

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We are wounded healers: we accompany our colleagues in their care of the dying; sometimes we are called to accompany them in their own deaths; We are wounded healers: we bear the stigma of the immeasurable pain of human suffering and dying as we stand before our patients, their families and our colleagues, filled with compassion, weeping, but, at times, with hands empty; We are wounded healers: we experience a deep sense of abandonment, loneliness and failure because we are unable to rescue our patients and our colleagues from a disease not of their own making; We are wounded healers: we find ourselves, at times, morally distressed because we are unable

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to stop the dreadful decisions that must be made for patient care in the midst of this terrible disease; We are wounded healers and bearers of hope and healing: each day as we say good-bye to our patients and colleagues we are afraid to return home to our families, knowing that we may carry

The profound virtuous act of the healer, the act that unites each of us, is embedded in the proclamation we all voiced when we dared to enter the world of health care.

reclaim confidence as instruments of healing and hope; Implementing strategies that will reach out especially to those have become isolated, withdrawn, feel abandoned, and think they have little reason to hope; Establishing local and regional interdisciplinary networks that provide long-term counseling, special services and resources as we reclaim human dignity and freedom and promote human flourishing among all persons; Working with local and regional health care systems, our colleagues in the health professions, and civic leaders to construct a long-term plan for continuing care and rehabilitation; As wounded healers and bearers of hope and healing, we bring to our world an elaborate and exhaustive array of experiences, competencies and a legion of unparalleled faith-filled experiences and expertise in the Catholic health care ministry, in education, administration, research across all domains of service to humanity. The profound virtuous act of the healer, the act that unites each of us, is embedded in the proclamation we all voiced when we dared to enter the world of health care.

This promise says: regardless of who you are, your gender, race, ethnicity, or religious persuasion, regardless of your illness or your life experiences; I am promising you my commitment that

illness and death to them; we are fearful about returning to our centers of care — the guilt of abandoning the sick when caring moments are desperately needed but sometimes beyond our reach; We are wounded healers and bearers of hope and healing: we are calling for urgent help to be relieved of these terrible burdens so that our ineradicable covenant to care for the sick and one another with compassion, the very soul of our call to be healers, will be re-affirmed. We want to reclaim human dignity and bring peace, healing and hope to one another and to our world, especially those who are abanRegardless of who you are, your doned, unloved and unwanted in our midst. gender, race, ethnicity, or religious In the midst of these convulsive persuasion, regardless of your experiences and in solidarity with one another and our colleagues, we illness or your life experiences; I am call on schools of the health profespromising you my commitment that I sions, organizations, associations and church groups to collaborate in: will care for you.

Forming listening sessions in order to share the wounds, the pain, multiples losses and anger we are experiencing I will care for you; I will try to heal your pain, to and to reaffirm and implement the power of the ameliorate your suffering, to help you accept the trilogy of health care (human dignity, freedom and limitations posed by the ravages of your illness. flourishing) among individuals and communities; I promise that I will accept your invitation to be Providing comprehensive professional with you when you are afraid, alone or dying; and resources (psychological, emotional, physical, to never abandon you along this journey.

As wounded healers and bearers of hope and pastoral, ethical, social work) for our colleagues to help them journey through their experiences healing, amid the threats of the coronavirus, we of grieving, anxiety, depression, to support those must never allow our promise be compromised. who have lost hope and self-confidence, and This is our vowed commitment to one another, to

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our colleagues, to the sick entrusted to our care, and to our nation and beyond. Let us reclaim the power of our promise: let us help one another to be healed of this terrible threat to human dignity, freedom and human flourishing. In this journey together we will be freed to bring the promise of hope and healing to one another and to every person entrusted to our care.

Finally, we ask Jesus, our model of the wounded healer, to protect us in our journey of healing and hope: To bring strength, confidence and an enduring hope to each of us and to our colleagues, our patients and their loved ones; To take time to care for ourselves and to listen to the voices in our own hearts; To endow us with courage to remain faithful to the promise of healing;

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To care for our patients, their families and our colleagues with compassion; To bring healing to the sick, peace and comfort to the dying and their families; To bring wisdom, compassion and confidence to our leaders; To grant eternal rest to the dead; and To comfort the mourners. Amen.

As wounded healers and bearers of hope and healing, how successful we are in bringing healing to each of us as wounded healers will determine how successful we are in fulfilling our promise to bring healing and hope to all persons entrusted to our care and to a suffering world.

BROTHER IGNATIUS PERKINS, OP, is a professor and chair of the School of Nursing, Spalding University in Louisville, Kentucky.

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Achieving Age-Friendly Care for Older Adults With the NICHE Program JENNIFER PETTIS, MS, RN

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merica is aging, and older adults comprise a more racially and ethnically diverse group than ever. In fact, there were 52.4 million adults over the age of 65 in 2018, an increase of nearly 14 million individuals in just 10 years. This segment of the population is expected to grow to nearly 95 million by 2060.1 The changing population composition, combined with the movement toward value-based care, has resulted in an urgent need for health care providers to implement systems of care that effectively honor the wishes of older adults and their families.2, 3 To address the urgent need to change the design and delivery of care for older adults, The John A. Hartford Foundation and the Institute for Health Improvement, with their partners, the American Hospital Association and the Catholic Health Association, launched the Age-Friendly Health Systems initiative in 2017. The vision for age-friendly care focuses on the 4M model — What Matters, Medication, Mentation and Mobility — as an indispensable set of evidence-based care approaches that support the dignity and selfdetermination of each older adult.

Ensuring that nurses are well prepared to recognize and meet the unique needs of older adults is a critical step in any organization’s process of becoming age-friendly. Nurses must be prepared to provide evidence-based care to older adults and be ready to lead teams to implement the changes needed to improve the overall quality, safety and value of care. Nurses Improving Care for Healthsystems Elders (NICHE) can enable nurses to do just that. NICHE, a program of the NYU Rory Meyers College of Nursing, is one of the original geriatric care models that focuses on the important contributions of nurses to influ-

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ence the health outcomes of older adults.

NICHE is an organizational membership program that aims to improve the care of older adults across the health care continuum.4 The NICHE practice model supports exemplary nursing care by employing four major levers: the Geriatric Resource Nurse (GRN) role; practice standardization and clinical guideline use; coordinated care transitions; and a population-focused environment of care.

The Geriatric Resource Nurse role is foundational to NICHE in that it positions frontline nurses as experts in geriatric nursing care. Nurses in this role serve as peer mentors, change agents and leaders in person-centered interdisciplinary care planning aimed at ensuring excellent care for older adults.5 The Geriatric Patient Care Associate (GPCA) and Geriatric Certified Nursing Assistant (GCNA) roles empower unlicensed nursing personnel in a similar fashion to the GRN. These staff, who often spend the most time with older adults in acute as well as long-term and post-acute care settings, serve as the eyes and ears of the team and are often the first to detect subtle changes in an older adult’s status. Ensur-

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TABLE 1

Alignment of NICHE Resources with Age-Friendly Health Systems Principles Age-Friendly Health System Principles What Matters

1. Know what matters: health outcome goals and care preferences for current and future care, including end of life 2. Act on what matters for current and future care, including end of life

Mobility

3. Implement an individualized mobility plan 4. Create an environment that promotes mobility

Medication

5. Implement standard process for age-friendly medication reconciliation

NICHE Protocols

Nursing Management Principles

NICHE Continuing Education Courses

Advanced care

Age-related changes

planning Frail hospitalized older adult Cancer care Perioperative care General surgical care

in health Health care decision making Sensory changes Family caregiving Sexuality Mistreatment and abuse

Caregiving Comprehensive

Preventing functional decline Preventing falls Urinary incontinence Preventing CAUTI Physical restraints and side rail use Preventing skin tears/injuries Fluid overload/ heart failure

Pain management Reducing adverse

assessment

Comprehensive health history

Decision making Elder mistreatment Caring for older adults with HIV/ AIDS Care of older sexual & gender minorities

Physical function Renal and GI

Fall prevention Function/mobility Pressure injuries Skin tears Urinary incontinence

Pain assessment

Medication management

Pain

drug events

6. De-prescribe and adjust doses to be age-friendly Mentation

7. Ensure adequate nutrition and hydration, sleep and comfort 8. Engage and orient to maximize independence and dignity 9. Identify, treat, and manage dementia, delirium and depression

Late-life depression Dementia Meal-time difficulties with dementia Excessive sleepiness Sensory changes

Cognitive function Oral health care Managing oral hydration

Nutrition Substance misuse

Data from NICHE program resources; IHI Age-Friendly Health System 4-M model.

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Assessing and managing difficult behaviors Delirium Dementia Depression Nutrition Oral health Sleep

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ing they are well versed in the most current, evidence-based practices to identify and act on such changes enables the entire care team to better meet the needs of older adults.

Second, practice standardization is achieved through nurse-initiated evidence-based clinical guidelines tailored to the needs of older adults.

Members of the NICHE program gain access to evidence-based resources, tools and education housed in the NICHE Knowledge Center, an online learning management system. The eightweek NICHE Leadership Training Program introduces new members to the NICHE nursing practice model, in which clinical leaders identify opportunities to improve care of older adults by implementing evidence-based nursing interventions into daily clinical practice.6 Third, recognizing the importance of wellcoordinated transitions of care, the NICHE program positions nurses to lead patients and families to prepare for transitions. For example, NICHE nurses learn best practices regarding caregiver readiness and other important nursing considerations when preparing an older adult for discharge from an inpatient care setting. The NICHE “Need to Knows” patient education tools and pocket cards support the consistent use of evidence-based practices, including teach-back strategies to prepare older adults and their families for a successful care transitions.

The fourth component of the NICHE model is centered on providing older adults with a population-focused care environment, set forth in the Acute Care of the Elderly (ACE) unit model.

Acute Care of the Elderly units employ strategies focused on enhancing older adults’ function and autonomy through robust use of adaptive equipment to overcome sensory, functional or mobility limitations. They also use simple strategies to promote orientation such as large-print calendars, clocks and whiteboards. Table 1 exemplifies how the NICHE program supports the AgeFriendly Health Systems initiative.

Currently, there are approximately 500 NICHE-member hospitals and post-acute care organizations in the U.S., Canada and Singapore.

NICHE’s positive impacts on patient, staff and organizational outcomes are well documented.7 For example, evidence shows that implementing NICHE resulted in decreases in restraint use and hospital-acquired urinary incontinence as well as increases in nurse satisfaction caring for older adults and a marked improvement in the overall nursing practice culture.8 Similarly, other NICHE

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members have reported clinical and organizational outcomes associated with NICHE including reduced falls, improved patient satisfaction, decreased use of inappropriate medication, improved cultural competence, improved detection and management of delirium, decreased lengths of stays and associated costs, and reductions in avoidable staff turnover.9 As Terry Fulmer, PhD, RN, noted during a recent IHI National Nursing Home Huddle, NICHE is the backbone of Age-Friendly Health Systems, and its long-standing success makes it an obvious choice for organizations seeking to provide the best possible care to older adults.

More information about the NICHE program and how to become a member is at www. nicheprogram.org, or contact us at support@ nicheprogram.org.

JENNIFER PETTIS is acting director, programs for NICHE.

NOTES 1. Administration for Community Living, “2019 Profile of Older Americans,” May 2020, https://acl.gov/sites/ default/files/Aging%20and%20Disability%20in%20 America/2019ProfileOlderAmericans508.pdf.

2. Terry Fulmer, Kedar S. Mate and Amy Berman, “The Age-Friendly Health System Imperative,” Journal of the American Geriatric Society 66, no. 1 (2018), doi: 10.1111/ jgs.15076.

3. Institute for Healthcare Improvement, “Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults,” 2019, http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx 4. Terry Fulmer et al., Nurses Improving Care for Healthsystem Elders, (New York: Springer, 2020).

5. Linda Bub et al., “The NICHE Program to Prepare the Workforce to Address the Needs of Older Patients,” in Geriatrics Models of Care, eds. Michael Malone et al.

(New York: Springer, 2015).

6. Nurses Improving Care for Healthsystems Elders, NYU Rory Meyers College of Nursing, 2020, https://niche program.org.

7. Allison Squires et al., “A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program,” The Gerontologist, (Nov. 4, 2019), https://doi.org/10.1093/geront/gnz150.

8. Jann Pfaff, “The Geriatric Resource Nurse Model: A Culture Change,” Geriatric Nursing 23, no. 3 (May-June 2002): 140-44.

9. Bub et al., “The NICHE Program to Prepare.”

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WE ARE GRATEFUL FOR THE WOMEN AND MEN OF CATHOLIC HEALTH CARE WHO HAVE BEEN CALLED TO CARE — We stand in awe of your grace under pressure, your dedication to serve, and your commitment to the needs of others. We remain in prayerful support of the work you do for the good of all. As we continue to weather this storm together, please take the time to care for yourself as you care for others.

Our God goes before you and will be with you; God will never leave you nor forsake you. Do not be afraid; do not be discouraged.

D EUT ERON OMY 31 :8

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NURSES

Reflection

Walk Quickly, Touch Gently JANENE PAPENDICK, RN, MA

“The Lord is my Shepherd; I shall not want. He makes me to lie down in green pastures; He leads me beside the still waters. He restores my soul... my cup overflows.” (Psalm 23:1-3,5)

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hen I applied to the St. John School of Nursing in Huron, South Dakota, in 1973, the school’s president, Sr. Mary Aloysilla, asked me why I wanted to be a nurse. I did not have a well-thought answer as my response was, “I like to walk fast.” She looked at me over the top of her glasses and simply said, “You’re in.”

Little did I know my answer was appropriate.

As a nurse, I have walked my whole career. Fast and slow. Up and down hallways, from room to room, building to building, up and down steps.

Thousands of times. Coming. Going. Hurrying from one place to another, from one thing to another, one patient to another.

Numerous polls consistently rank nursing as one of the most trusted professions. I thrive in that world and am happy to say that am a nurse.

We are a diverse group. We come from different places, backgrounds, beliefs systems, values, paradigms, passions and priorities.

We are wise to become team members by uniting with peers in our departments or units. We are wise to align ourselves with the mission and vision of our organizations.

We are wise to know our own personal and professional mission. We are wise if we practice what we preach — if we listen to and implement the advice that we give to others and each apply it to our own life.

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The thing that most nurses likely would say about ourselves is that we care about our patients.

Our patients may be individuals, families or entire communities. From deep inside, we want good outcomes. We want independence for our patients. We want healing even if a cure is not possible. In the end, we want ease and comfort for our patients.

The most common thing that flows among nurses and the thing that we all share is touch. We touch people.

I had to learn how to touch people in the beginning. My hand on a patient’s arm when I started an IV, my hand on a shoulder when listening to breath sounds, my hand adjusting a patient or lifting their legs to help someone into a better position.

A nurse’s touch is more than physical. We touch people with our gaze. We touch people with our presence. We touch people with our reactions and with our words. We touch with our hearts.

Touching others is very natural for some nurses.

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For others, it is a learned art. It is something that we keep practicing every day.

Today, we touch people with gloved hands. We speak to them through masks and face shields.

Despite these barriers, we continue to touch our patients with the calmness of our voices and the reassurance of our eyes. We tap in to their energy with our energy through a balanced combination of skill and efficiency, knowledge and attitude.

As a young nurse, one of my supervisors empowered me with this advice: “When a door opens up, you just have to walk through it.” She was speaking about her own choice, a change from being our night-time supervisor to her new daytime position. It was a hard decision because of the camaraderie and confidence we had in each other during the night shift.

To the best of my ability, I have walked through the doors that opened. In spite of hesitation, insecurities or fear, there were times that I was the expert in the room. I needed to take responsibility. I needed to project calmness in a room full of nervousness. I needed to be the leader.

For 13 years of my career, I worked as the director of nursing in long-term care. During some of the first days of my new job, I was green and unsteady. The environment was much different than what I had imagined.

Early on, I met one of the residents who was dying. This resident often was not kind to those around her, especially her caretakers. When her death was near, I called all the staff who had been working on the wing to her room. It was right that they be present. They came. They laid a hand on her. They said the Lord’s prayer for her.

I was moved tremendously by their loyalty. I was amazed at their love for this resident — someone who did not show appreciation for all they did to keep her comfortable. Somehow, they had mastered the art of accepting her, not judging her.

They responded to her unkindness with kindness.

In that moment I knew that these people, this staff — my colleagues — were special. I knew we were standing on sacred ground.

I have always been part of a team. Part of the team that delivered a baby when the doctor did not make it in time for the birth. Part of a team that

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organized an emergency C-section when a mom and baby were too fragile for a 28-mile ambulance ride. Through phone calls, contacts and rapid collaboration, we found a doctor that would come to us. A healthy baby boy was born.

I was part of a team that kept a woman from crashing until her temporary pacemaker could be inserted. Part of a team that welcomed families and patients like old friends to our clinic. Part of a team that could converse about a patient’s health concerns like they were our very own. Part of a team that has kept working at quality improvement and streamlining how we plan care and record our own actions. I am grateful that I have been part of so many diverse, knowledgeable, wise and faithful teams.

Nurses are accustomed to change. This time of COVID-19 has brought deep change — change so great that it feels it can move the earth and the gravitational pull under our feet. However, the values, ideas and the basic actions to which nurses cling have not changed.

Florence Nightingale revolutionized the profession of nursing by teaching us to open the windows to let in the air and sunlight. She taught us about feeding our body with nutritious food. She said to clean up and sanitize our environment and to be orderly. She put people at ease, and she held the hands of those who were dying.

When we consistently do these things that have not changed — and will not change, we create trust. We evoke confidence.

I keep walking. Fast — but slower when it is required. I avert my eyes to look down at my feet especially when this path is uneven or slippery.

When I am confident in the steps, I can raise my head again and look toward the horizon — the future.

Nurses will keep putting down one foot in front of the next. We move forward. We trust we are on the right path.

JANENE PAPENDICK of Aberdeen, South Dakota, recently retired as a full-time nurse. Proud of her profession, she remains on call on paper and emotionally in her heart.

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Illustration by Jon Lezinsky

TWO ZIP CODES, A WORLD APART St. Louis Neighborhoods Reveal Pandemic’s Toll, Need for Change SALLY J. ALTMAN, MPH

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n 2012, everything was finally coming together for Steven Jones. He was in his twenties, making decent money as a grill master at Red Lobster. He was in love and had three daughters with a fourth on the way. Then he suffered through a five-day seizure.

Doctors said Jones had developed a rare form of epilepsy, one of the worst. He went into intense rehab and, as a result, had to miss the birth of his baby girl. As he learned to walk again, the seizures continued, and they ate chunks of his memory.

It took years to get the right medication balance to normalize his brain function.

Last year, before COVID-19, he was able to find a slightly better-paying job, driving a scooter around a downtown parking garage picking up trash. But that meant that he would no longer be eligible for Medicaid, food stamps and a monthly disability payment. By the time child support for four daughters was subtracted from his paycheck, he barely had enough to pay rent. Then, in February, he learned of a janitorial opening at the Boeing Learning Center in St. Louis County. It meant a two-hour bus trip each way, but it would pay $18 an hour. He’d just finished the training when the county went into lockdown. Because he had not started work, he was ineligible for unemployment payments.

If you are searching for yet another example of how the pandemic falls most heavily on people of color, on those with chronic illnesses, on those living in underserved neighborhoods, Steven Jones is your man. His life and those of others nearby lay bare the health inequities that St. Louis and urban centers around the country must come to grips with as they also try to move on from the pandemic.

For decades, African Americans have suffered from higher rates of chronic diseases, including diabetes and heart ailments that make them more vulnerable.

When COVID-19 arrived, it immediately exacted a toll. In June, the St. Louis PostDispatch reported that African Americans made up one-third of Missouri’s coronavirus deaths, while representing just 12% of the state’s population. In St. Louis and St. Louis County, they were dying at nearly double the rate of whites.

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Photo by Matt Marcinkowski

Steven Jones, shown in his Preservation Square apartment near downtown St. Louis, is epileptic and has struggled to find work.

Well-resourced families are beginning to see how their fate and future are increasingly tied to families who lack adequate insurance coverage or have none at all. They have been reminded that charges to insured individuals — their deductibles, co-pays and premiums — include the costs of unreimbursed care. They were also learning through news coverage that impoverished and uninsured essential workers might report to work when ill and pass along infections to them or their loved ones.

As happened on the Titanic, citizens region wide — whether in steerage or luxury accommodations — are beginning to recognize they could all could be going down with the ship.

Jones lives in a neighborhood known as Preservation Square, just a mile west of downtown St. Louis in the 63106 zip code. Residents living in 63106 have been identified in a groundbreaking report jointly prepared by Saint Louis University and Washington University as having the most problematic social determinants of health in the region.

A key data point from that report: a child born in 63106 in 2010 had a life expectancy of 67 years.

A child’s life expectancy increases by almost two decades, to 85, in 63105.

Zip code 63105 covers the municipality of Clayton, the St. Louis County seat, with the white population at about 78% and one of the highest

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per capita incomes in the region. Zip code 63106 has six times the unemployment rate, almost eight times the poverty rate and less than a quarter of the median income of Clayton. The median income varies greatly, from $15,000 in the St. Louis zip code to $90,000 in the Clayton zip code.

The researchers might have expected that their report would shock the collective conscience of their community. The report was timely, surfacing just a few months before the police shooting of Michael Brown in Ferguson, a municipality located in north St. Louis County. The tragic circumstances drew more attention to the report, which was often cited by the Ferguson Commission that had been formed by then-Gov. Jay Nixon in the wake of the unrest surrounding Brown’s death. The commission drafted a report with 189 proposals to address racial equity issues regionwide, including expansion of Medicaid coverage in Missouri.

But Medicaid expansion went unaddressed for six years until this summer.

Perhaps it took a pandemic, a cratering economy and a vivid video showing a Minneapolis police officer kneeling on George Floyd’s neck as he sought mercy and cried out to his mama, to create enough empathy for action.

All of that shone “a spotlight in a different way,” said Riisa Rawlins-Easley, chief of staff at the St. Louis Regional Health Commission. She

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noted that previous incidents including the death of Michael Brown awakened concerns among many for marginalized communities, but with the pandemic, “we were at home. You couldn’t turn away as easily.”

In Missouri, voters went to the polls on Aug. 4, 2020, and approved Medicaid expansion, making the state the 38th in the nation to do so and ensuring that 230,000 more residents would be eligible for coverage. The measure passed with 53% of the vote.

Currently nearly 100,000 people — one in 10 of the total population — are uninsured in metropolitan St. Louis. That will change beginning in July 2021, unless legislative opponents find a way to impede or halt implementation.

The ballot measure certainly got Jones to the polls, although after his new job dissolved, he would have been able to get back on Medicaid anyway.

Still Jones knows that Medicaid alone won’t address all the inequities or the health care challenges he faces. And the people active in delivering services to marginalized populations know that’s true as well for all the people they have been struggling to serve.

“People who are more into politics than me have said it’s going to help people,” Jones said.

But Medicaid is perplexing as far as he is concerned. “I couldn’t find anywhere where I could read every page and see all the fine lines,” he said.

“I haven’t seen the actual paperwork. As easily as I can find somebody’ else’s criminal record for $5.99,

I should freely be able to look up bills!” (He could have found the ballot measure’s text through the Missouri Secretary of State’s website, but by now he is used to obstacles and complications. This is unsurprising to public health experts. There’s a tendency among many disadvantaged residents to assume the system won’t work for them because it hasn’t in the past.)

At this point, Jones certainly could use a dentist. His tooth is halfway gone, and the nerve has been exposed for months. “It only hurts at night now,” he says, relief in his voice. “That’s how I know it’s bedtime. After a while, salt doesn’t work, and you bite your tongue because the Orajel numbs your mouth.” Because of his epilepsy medications, he can’t take aspirin.

What Jones didn’t know is that Medicaid added adult dental coverage in Missouri in 2016, until a reporter mentioned it to him.

“I just figured you had to have some private insurance,” he said. But he isn’t enamored with the options. Only two clinics are within a manageable commute and offer dental services for adults using Medicaid, and they are crowded with people seeking health appointments and COVID19 testing.

Meanwhile, regarding his epilepsy, the Supplemental Security Income program wants records from a general practitioner, not just his neurologist. “I don’t have one,” he says.

In recent months, Before Ferguson Beyond Ferguson, a nonprofit racial equity storytelling project, has been shining a light on the lives of

A TALE OF TWO ZIP CODES 63105

63106

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Clayton

North St. Louis

Life expectancy: 85 years

Life expectancy: 67 years

Racial makeup: 78% White | 9% African American | 14% Other

Racial makeup: 95% African American | 2% White | 3% Other

Unemployment: 4%

Unemployment: 24%

Percent below the poverty line: 7%

Percent below the poverty line: 54%

Median household income: $90,000

Median household income: $15,000 0

5

10 miles

Sources: City of St. Louis Department of Health – Center for Health Information, Planning, and Research; Census 2010, MODHSS, Death MICA 2010 Graphic is from “For the Sake of All,” in 2015. It is used with permission of Health Equity Works at Washington University.

Notes: ZIP code life expectancies were derived using population counts from Census 2010 and deaths from Death MICA 2010. Total percentage for race may exceed 100% due to rounding.

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Photo by Colter Peterson/St. Louis Post-Dispatch

people in 63106 as they deal with the daily impact of the pandemic.

Steven Jones drew the project’s attention.

So did Tyra Johnson, a single mother, with two small children and a newborn. Johnson has had to abandon her dreams of starting online college courses because she is overwhelmed trying to manage her little ones in a small apartment in a neighborhood where it’s too dangerous to let her kids even go outside and play. Disciplined and resourceful, she has been keeping her kids’ days structured and their learning uninterrupted. But her Tyra Johnson said her St. Louis neighborhood isn’t safe enough for older two, Meegale, starting first her children Madison, left, and Meegale Hundley, to play outdoors grade and Madison, entering prethere.

K, are stir-crazy from their isolabecame available. She has felt trapped ever since tion and her own life is on hold.

Fortunately Johnson did have access to health and has begun dreaming again of a rural outpost.

But in other ways such a move makes no sense. care and delivered her newborn without incident.

Her son and granddaughter live in Florissant, Though she is currently in good health, Johnson is subject to what public health experts call toxic and her father is in Overland, communities in north St. Louis County. If she were to leave, Danstress owing to her precarious circumstances.

Johnson is terrified that her kids might con- iel said, “I would be sentencing myself to seeing my family even less often than I do now with this tract the virus.

“You don’t want your kids to go outside and pandemic going around.”

Moreover, what if Daniel got sick? Could she then, you know, they get any type of virus,” she prevail on a friend or acquaintance to help her? said. “It’s just like, I can’t afford it, you know?”

As chief of staff at the St. Louis Regional Health Even before the pandemic, Johnson would drive her children miles away for a playdate in a Commission, Rawlins-Easley is familiar with situations like these that are borne from decades of park.

“I don’t allow them to play around here,” she systemic racism and a health care system tied to employment. said.

Created in 2002, the commission is a collaboraAlso living on edge is Kim Daniel, a 54-year-old caregiver, who worries that a long-standing heart tive effort of St. Louis City, St. Louis County, the ailment makes her easy prey for COVID-19. But state of Missouri, health providers and community members to improve the health of uninsured she has more to contend with than just that.

Daniel has lived in abject fear ever since the and underinsured citizens in the St. Louis metroearly hours of April 16. That’s when a bullet from politan region. As the plight of underserved famian automatic weapon slammed into her apart- lies became ever more acute, the commission in ment while she was sewing face masks. Now she 2012 organized a delivery system called Gateway dreams of moving to a safer place. But she will to Better Health. It has provided up to $25 million need to find a home where she will have easy and annually in funding for primary and specialty care frequent access to health care because of a con- as well as other outpatient services. The Gateway genital heart defect that has taken her to death’s to Better Health program has provided coverage to nearly 64,000 uninsured and under-insured door several times over the course of her life.

Daniel once lived in rural Arkansas and was adults. (Rawlins-Easley noted that SSM Health quite comfortable there. But physicians in Mem- and Mercy Hospital St. Louis participate as inphis — the nearest big city — told her that St. Louis network locations for Gateway.)

“When we think about our work, we often talk was her best bet for the specialized medical care she needed. So Daniel returned to her hometown about the dual pandemic of racism and COVIDand took the first housing accommodation that 19 that we’re grappling with right now,” Rawlins-

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Easley said. “Institutionalized racism is baked into our system. We have rates of fetal and maternal mortality that are akin to third world countries.

Black women are four times more likely to die in post-pregnancy than white women, and babies are at least three times more likely to die before their first birthday.”

Along with all that, Rawlins-Easley adds, is the mistrust and uncertainty many African Americans bring with them when they interact with health care systems. These doubts date back generations to times when some communities across the nation simply refused to provide care for people of color at their local hospitals and infamously to a time when U.S. Public Health researchers over several decades in the middle of the 20th century charted the course of syphilis in 600 black men.

Officials involved with the Tuskegee Experiment in most cases never told the men they had the disease, and, in some cases, denied them treatment.

The study, once it was exposed in the 1970s, led to distrust for the medical system so great that it affected the life spans of black men for generations to come.

The distrust endures.

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efore Ferguson Beyond Ferguson, a nonprofit racial equity storytelling project, has been shining a light on the lives of people in the 63106 zip code as they deal with the daily impact of the pandemic.

The neighborhoods within that zip code lie just west of downtown St. Louis. Nearly 12,000 people — about 95% of them African American— live in the area’s slightly more than two square miles. In 2014, a study by social scientists at Washington University and Saint Louis University reported that the zip code’s social determinants of health — factors such as education, employment and income levels as well as access to medical care, crime, and housing — were the most problematic in the region.

Under the guidance of the nonprofit, Before Ferguson Beyond Ferguson, St. Louis media

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Courtnesha Rogers, another 63106 resident with small children, is already thinking about the prospect of a COVID-19 vaccine. “If my kids are required to get vaccinated, I’m gonna homeschool them,” she said.

Kim Daniel is wary as well: “I am not at all willing to accept a vaccine, at least not in its beginning stages. It takes time to know the stability of a drug or vaccine, and its effects on populations.

However, once the vaccine has been in usage for a decent span of time and science learns there are no negative impacts of the vaccine or adverse effects, then I will consider the option. My hope is legislators will not pass legislation, forcing the skeptical to accept a vaccine against their volition.” Under the circumstances, that sounds absolutely prudent on Daniel’s part.

Rawlins-Easley says that her organization, along with facilitating direct services and bringing COVID-19 testing to urban neighborhoods, has developed a communications strategy. “We recognized a lot of communication going on was confusing and contradictory and not a lot of it was targeted specifically to underrepresented communities,” Rawlins-Easley said. “So we quickly

outlets that normally compete with one another agreed to collaborate and carry stories in serial fashion — a new “episode” approximately every six to eight weeks. So far six families have been covered with one or more installments; reporting and research is underway for two more families.

Notably, none of the people in these stories turned out for the protest demonstrations in the wake of the police killing of George Floyd and the inequities laid bare over the course of the pandemic. These families say they are almost entirely sympathetic to the Black Lives Matter movement, but they have so much on their plates that it’s nearly impossible for them to participate.

They are truly among the unheard and these stories give them a voice.

The stories can be found at https://before fergusonbeyondferguson.org/63106-project/

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pulled together a communications strategy to dispel myths that existed. We partnered with Blackrun organizations that already had established relationships.”

The result: A portal called PrepareSTL, a site for all things related to COVID-19, including a straightforward down-to-earth video providing useful guidance on how to deal with the pandemic.

PrepareSTL features a video from Rebeccah Bennett, founder of the InPower Institute, an organization that focuses on community healing. In it she addresses the distrust that Black residents feel toward government, the health care system and the media.

“Many of us are on the streets where we don’t have protective gear on... because we don’t actually believe what we are hearing,” Bennett says.

“We don’t trust the institutions that are giving us this information. Many of us don’t trust our health care systems … We haven’t been treated with care and professionalism. There are those of us who don’t trust the media … What you need to know is we are out here dying. We aren’t just dying later.

We are dying first. It is incumbent on us to take this thing seriously. Why? Because our Black lives matter. So what is it that you need to know to stay as safe as possible …”

This is common sense information a guy like Steven Jones can use.

“I just got informed that us as Black men, we don’t have regular doctors and that’s why we are leading in all these diseases,” Jones said. “Well, who tells us we need to go? We didn’t learn that in health class, that we needed to go to the doctor even if something wasn’t wrong with us. If y’all let me know these things, I will do these things.”

This article includes additional reporting from JEANNETTE COOPERMAN, AISHA SULTAN and RICHARD H. WEISS SALLY J. ALTMAN has devoted her career in public health to working with key stakeholders on health access issues as a health care administrator and a journalist. JEANNETTE COOPERMAN is a St. Louis journalist and an essayist for Washington University’s The Common Reader. AISHA SULTAN is a nationally syndicated newspaper columnist, award-winning filmmaker and features writer.

RICHARD H. WEISS is founder and executive editor of Before Ferguson Beyond Ferguson, a nonprofit racial equity storytelling project.

RELATED RESOURCES Before Ferguson Beyond Ferguson project: https:// beforefergusonbeyondferguson.org/.

“Sick Alone, Mourning Alone: COVID-19 Hits the Elderly and African Americans the Hardest,” St. Louis Post-Dispatch, June 8, 2020, https://www.stltoday.com/business/local/sick-alone-mourning-alone-covid-19-hitsthe-elderly-and-african-americans-the-hardest-in/ article_bab7f387-0667-51d6-b29f-4c0660b3e017.html.

“Clayton Conundrum: St. Louis County Seat Tackles Race Relations, St. Louis Post-Dispatch, March 8, 2020, https://www.stltoday.com/news/local/metro/claytonconundrum-st-louis-county-seat-tackles-race-relations/ article_49d560cd-6ff8-5d17-99c9-05ea3a5c8e52. html.

PrepareSTL: https://www.preparestl.com/, and PrepareSTLvideo: https://www.youtube.com/ watch?v=e5Juom06_XU&feature=youtu.be.

“Many of us don’t trust our health care systems …

We haven’t been treated with care and professionalism.

There are those of us who don’t trust the media …

What you need to know is we are out here dying.

We aren’t just dying later. We are dying first. ” — REBECCAH BENNETT

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A Path to Renewal in Work and Leadership Making the Case for Inner Transformation and Prophetic Imagination TIM MORAN

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e are more than six months into the COVID-19 crisis, a period of immense disruption in the economy, in consumer patterns, and in how we view work and leadership. Given the confusing, unpredictable nature of the present moment, I have reflected on several distinct but intersecting perspectives on the importance of transformational thinking, leadership and formation in Catholic health care.

I begin with some questions: Have traditional approaches to the formation of Catholic leaders had their day? Are the principles that served to bridge Catholic health care from the sponsoring congregations of sisters to the first generations of lay leadership in the 1990s now in need of renewal?

What is the nature of leadership formation needed for the distinctly different and demanding future that the next generation of Catholic health care leaders will be called upon to shape?

Let me make an observation about the road Catholic health care leaders have taken and where we find ourselves today. In many respects, in the year 2020, mainstream America is becoming more aware of the issues that many leaders in the Catholic health ministry have been concerned with all along: economic inequity, social determinants of health, racial inequality and social justice, among them. Yet, at the moment of this emerging mainstream awareness, it is surprising that Catholic health care leaders are not being sought out as central authorities and voices of wisdom in numbers consistent with the tremendous resources and investment that have been committed to formation. How to interpret this? Is it possible that over time leaders in Catholic health care have overemphasized the language of transformation,

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while undervaluing the core elements that drive it? I suggest that traditional approaches to formation need to be changed to renew allegiance to two pillars of formation that were both integral to the sisters’ success in guiding the ministry through their challenging times and are equally critical in these changing times: First, that inner, personal transformation is the foundation for organizational and community change; and second, that tapping the prophetic imagination is a critical skill in envisioning and giving voice to a continually renewing ministry.

‘LETTING GO’ TO ENTER NEW, SACRED SPACE

A wonderful description of the difficulty and necessity of change comes from Richard Rohr, a Franciscan priest and contemplative, and the founder of the Center for Action and Contemplation, in Albuquerque, New Mexico. Rohr explains the process of transformation by referring to “the three boxes”: 1) Order, which eventually disintegrates into 2) Disorder, which seeds a new form of 3) Reorder. He explains his concept this way: “The temptation is to become overly invested in what we know, the current order, what’s comfortable.

Certain as the dawn, comes imperfection, failure and inadequacy of that order. Then comes disor-

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der and the necessity to reframe and see things differently.” Rohr goes on, “Whenever we’re led out of normalcy into open space, it’s going to feel like suffering, because it is letting go of what we’re used to. This is always painful at some level. But part of us has to die if we are ever to grow larger.

If we’re not willing to let go and die to our small, false self, we won’t enter into any new, sacred, space.”1 Rohr is focused on the process of inner, personal transformation and spiritual growth. Interestingly, Kurt Lewin, the father of human systems change theory, described his three-stage approach to organizational change essentially the same way, using blocks of ice as a metaphor.

His “Unfreezing-Change-Refreezing” model provided the basic structure for many change management models in use today.2 We’re all familiar with initiatives that describe the current state, the need for change through a transitional state, and a future state required for success.3 All of that work is traceable to Lewin.

For leaders in Catholic health care, the crisis posed by the events in 2020 requires that we engage in inner, organizational and community transformation, despite our unpreparedness or uncertainty about how to move. The cycle of order, to disorder, to a new order is at work, and how we engage it is important. The sisters proved that when leaders are able to “let go” and set ego aside, reimagination becomes possible, “sacred space” can be entered and bold results can be achieved.

Many Catholic health care leaders demonstrate the authenticity, creativity and resilience required to lead through uncertainty, mixed signals and anxiety toward possibilities that they cannot fully picture. However, other leaders in Catholic health care appear less interested in being shaped by a process of inner transformation.

Instead, they model a form of leadership more in line with the values and language that any public or private corporation may have. They offer little of the model set by the lived experience of the sisters for faith-based leadership in a crisis. If we are concerned about the capacity of emerging leaders to act on opportunities for audacious change, then we must be sure that formation practices are still in touch with the personal, inner transformation that made the sisters’ actions possible. In order

to authentically lead the organizational change model that Lewin taught and the social and community transformation the sisters achieved, leaders in Catholic health care must be engaged in the constitutive personal, inner transformation that Rohr has described.

Why is inner transformation critical? Bill George, former CEO of Medtronic, Harvard Business School professor, and author of Authentic Leadership, puts it this way, “To be effective leaders of people, authentic leaders must first discover the purpose of their leadership. If they don’t, they are at the mercy of their egos and narcissistic impulses. To discover their purpose, authentic leaders have to understand themselves and the passions that animate their lifestories.”4

NATURE’S REINVENTION AFTER CRISIS

In an earlier article published on LinkedIn in April 2020 called “Some Leaders Break in Crisis, Others Are Broken Open,” I introduced the concept of “serotinous leadership.”5 It is based on the ecological process of serotiny whereby certain plants reproduce in response to a specific environmental trigger. For example, I considered the lodgepole pine and the Yellowstone National Park fire of 1988, in which the seeds of the lodgepole

The sisters proved that when leaders are able to “let go” and set ego aside, reimagination becomes possible, “sacred space” can be entered and bold results can be achieved.

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pine had been held fast for many years in cones hardened by resin, until fire burned the trees. As the fire melted the resin, the lodgepole seeds were released and dispersed through wind and gravity.

Even as fire laid waste to the forest, serotiny had broken open the lodgepole’s cones and the forest’s future with them.

For the serotinous leader, crisis acts as a crucible of formation and evolution, dispersing seeds of renewal that the leader uses to help individuals, teams and organizations move ahead, not in a return to what was, but in a turn to new and better ways forward.

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You may know a serotinous leader. You recognize her by her grit, to be sure, but that toughness is balanced with humility born of personal transformation. She likely tells stories about the way a fire of crisis burned the ground beneath her and melted away assumptions and biases that no longer fit changing circumstances. She expresses gratitude for the opportunity to find renewal, to do better. And through her own vulnerability, she builds trust as a foundation for the meaningful and fruitful relationships upon which all good organizations — and a renewed future — are built.

The self-described “leaps of faith” that many sponsoring congregations took in the 1990s have often been called “innovative.”

They were much more than that.

In my view they were tremendous acts of serotinous leadership, as the sisters set ego aside, let go of traditional sponsorship models and transitioned their legacy of care within a changing environment to the hands of lay leaders. So too, they passed on an equally tremendous responsibility to the ensuing generations of Catholic health care leaders: the sponsors trusted them to learn and model a form of leadership with humility and courage that they too would recognize the right moment to sublimate one’s ego, “let go” and “seed” a different way forward, when the current order would no longer be sufficient.

organization with a serotinous mission, one that continually adapts and regenerates. In its brief history, St. Joseph’s has provided pediatric dental and behavioral health services that did not exist in the community before then. Just recently, in the face of the COVID pandemic the organization pivoted to add programs and services to meet the basic nutritional needs of families and children who are food insecure.

President of CHI St. Joseph Children’s Health and a Lancaster native, Philip Goropoulos,

If change is inevitable, what resources can leaders in Catholic health care turn to for help? The objective is not to simply manage change; it is much bigger than that. Leaders must set themselves on paths to inner, organizational and community transformation, both for themselves and for those who look to them for guidance.

EMERGING FROM CRISIS TO FLOURISH

Serotiny is at work in organizations, as well. One example comes from Lancaster, Pennsylvania.

In 2000, the local Catholic hospital, which had been an anchor institution since its founding in 1878, was sold by its national health system parent. The hospital’s significant capital needs and its inability to keep pace with local hospital competition brought its century-plus legacy to an end.

Through the lens of the historical order, this was a failure. Yet in the crisis, the seeds of renewal were cast in the form of a new community trust.

All of the proceeds of the hospital’s sale were held within the trust to establish a new ministry, St. Joseph Children’s Health, which now flourishes.

In my view, St. Joseph’s leaders have built an

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recently celebrated a St. Joseph milestone: the delivery of 20,000 meals during the COVID-19 pandemic. Goropoulos describes an organization and an approach to leadership that embraces change. “We keep it simple. We come to one another with a community need in mind and ask, ‘I’m really worried about this, are you worried, too?’ That’s how we arrived at the rapid development of a meal distribution program that started with no kitchen and grew from a modest program of a hundred meals a day to one that serves a thousand meals to two hundred residents. It wasn’t in the strategic plan, the needs and our response to them, emerge. None of us could have imagined that a project we thought would be needed in the community for a few weeks would still be working to help our friends and neighbors months later.”

TAPPING PROPHETIC IMAGINATION

If change is inevitable, what resources can leaders in Catholic health care turn to for help? The objec-

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tive is not to simply manage change; it is much bigger than that. Leaders must set themselves on paths to inner, organizational and community transformation, both for themselves and for those who look to them for guidance. Even amidst such uncertainty, this is the path to minimize the losses and move toward renewal as boldly and as creatively as possible.

Rohr offers an insight for leaders to consider by describing the journey from the familiar to the new, through the example of the Old Testament prophets. “The role of the prophet is to lead us to sacred space by deconstructing the old space.” Rohr’s reference is echoed by another student of the prophets, Walter Brueggemann, who taught at the Columbia Theological Seminary and authored several books including The Prophetic Imagination.

What distinguished the prophets? Brueggemann says, “The prophets were of the traditions of their times, and they were completely uncredentialed and without pedigree. They weren’t specially educated or privileged to speak out. They were everyday people in the same way that we are.

They were poets and storytellers, who gave voice to a new way of seeing.” Brueggemann continues, “The prophets imagined their contemporary world differently. They were moved, as is every good poet, to think outside the box and describe the world differently according to their insight.” Coming alongside Rohr and George, Brueggemann says that in our ever-present need to adapt to changing circumstances, “The task is reframing, so that we can re-experience the social realities that are right in front of us, from a different angle.”6 The prophetic imagination is relevant today, as leaders in Catholic health care confront and respond to challenging times. In this sometimes overwhelming experience of disruption, we can acknowledge that the world we trusted in is vanishing and the territory we are entering is unfamiliar. We can recognize that past frameworks are no longer sufficient. We can, in the midst of crisis and disruption, engage with others to reframe a new order. We can tap our own prophetic imagination to envision the future and the path to it.

strengthen resilience and well-being, challenge and change habits so as to see our changing circumstances differently, and eventually emerge to a reimagined future. How do we undertake these tasks when our culture (and in many instances, our work cultures) don’t seem to have given us tools for such transformation?

After years of studying the prophets, Brueggemann suggests that we “pay attention to the nuance of language.” It is a suggestion I second, and one I have acted on in my own career. I also draw from Diane Ackerman’s book, An Alchemy of Mind. She suggests that “Metaphor is one of the brain’s favorite ways of understanding the ‘this and that’ of our surroundings, and reminds us that we discover the world by engaging it and seeing what happens next. The art of the brain is to find what seemingly unrelated things may have in common, and be able to apply that insight to something else it urgently needs to unpuzzle … It is the leap of thought from one set of conditions to an analogous one, that brings us that truly great idea or action.”7 After many years as a corporate strategist, I now come alongside executives, teams and boards, using creativity, poetry and

We can recognize that past frameworks are no longer sufficient. We can, in the midst of crisis and disruption, engage with others to reframe a new order.

THE ROLE OF CREATIVITY IN LEADERSHIP

The central tasks in a time of crisis are to

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other arts, to help them give voice to their own prophetic imagination; to engage in a process of seeing differently so they can help their organizations discern the path from order, to disorder, to a compelling new order. We carry this out in strategic planning, leadership development, and team formation and effectiveness. In response to the COVID crisis, we are developing similar tools to help nurses, physicians and other caregivers find new paths to resilience and well-being, both growing concerns in hospitals and health systems across the country.

I come back to the central questions: Are current models of Catholic health care leadership getting us to where we need to be? Do they provide the underpinning and active support for the inner, personal transformation that is the prerequisite for meaningful, authentic organiza-

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tional and community change? Is it possible that we are unconsciously accommodating, hedging and enabling the next generation of leaders to be articulate in the language but unpracticed in the characteristics of the ministry that enabled the sisters to enact bold and prophetic change? As the next generation of leaders attends to the tension between margin and mission, they must reckon with personal transformation and prophetic imagination as critical skills rather than the artifacts from sisters of a bygone era.

John O. Mudd, retired senior vicepresident of mission leadership at Providence Health and Services, described a discovery he made as he organized and conducted leadership formation for aspiring leaders in that system. He wrote: “In formation programs, the organizational and personal dimensions are inseparable. That connection was not as clear to those of us who were putting together formation programs in the early days. When we were planning the pilot formation program for Providence Services, a wise sister summarized what we wanted to explore as basically three questions: “Who is Providence?”

“Who am I?” and “Who are we together?” That’s it in a nutshell. Today we understand that the “Who am I?” question is not an accidental by-product of the formation experience, but a constitutive element. This realization has crucial implications for what we do in formation and how we do it.”8 The sisters spoke and acted from vulnerability, humility and imagination, derived from their own inner, personal transformation. That transformation was made manifest through a deliberate and intentional focus on integrating their personal spiritual journey with their ordinary daily work.

They were in touch with what Bill George called “the passions that animate their life stories,” and they were skilled in the nuance and use of language, poetry and art to inspire others. How can we hope to animate emerging leaders in Catholic health care, now often several generations of leadership removed from those who worked alongside the sisters, if formation is not first and foremost personal? Brueggemann described it simply, “The prophets imagined their contemporary world differently, but according to the old tradition. They bridged tradition and imagination.” It’s up to formation leaders to meet the emerging generation of Catholic health care leaders differently, more creatively, in tapping their prophetic imagina-

tions to traverse the same bridge.

Adjusting our course to more fully develop inner, personal transformation rooted in the values of Catholic health care, and tapping the imaginative power of prophetic imagination, can sound preposterous on its face. Deeper personal engagement as well as the need for humility, a rec-

This is what leaders are called to do: to use crisis to produce a crucible of personal change that is necessary to lead and form others.

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ognition of limits, the need to listen to contrary or conflicting opinions before acting, especially in times of uncertainty, run counter to a prevailing notion of American corporate leadership, in which the “heroic” CEO or C-suite feels compelled to provide order and control, at all times and in every circumstance. To be sure, an adjustment to vulnerability and humility, and attention to the nuance of language in values-based leadership, will not appeal to all leaders. But I believe these are necessary, constitutive parts of the deeper calling of Catholic health care leadership, as it re-roots its serotinous mission in response to the issues of 2020.

INSPIRING LEADERS TO ENVISION A NEW ORDER

In the years I served as a system-level strategy executive, I was often asked to draw on my experience to introduce new board members, executives and others to the history, mission and strategies of the organization. I would describe the health system as an ongoing experiment. I believe it is an equally appropriate way to describe the Catholic health ministry as a whole. It is an ongoing experiment in resilience and renewal, born from the legacy of the sisters and their response to challenges and the signs of their times, and continuing on with each new generation of leaders.

The signs of these times, as we can see in daily news accounts, underscore the fact that the direction an organization might take in times of crisis is precarious. As the old order crumbles, as business assumptions are rendered invalid by changing circumstances, leaders in Catholic health care must be open to disorder, and then, drawing upon humility and vulnerability, invite others to engage

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the prophetic imagination in order to paint the picture and tell the story of renewal. This is what leaders are called to do: to use crisis to produce a crucible of personal change that is necessary to lead and form others. The models for inner personal transformation and broader organizational and community change share similar characteristics, and they are deeply related. After all, what are organizations and communities, other than a collection of individual inner transformations, woven together toward a common purpose?

TIM MORAN was system vice president for strategy and alignment at Catholic Health Initiatives.

He is president of Creativity in Leadership, and can be reached at timsmoran@yahoo.com.

NOTES 1. Richard Rohr, “The Three Boxes,” Center for Action and Contemplation, December 2016.

2. Kurt Lewin, “Frontiers in Group Dynamics: Concept, Method and Reality in Social Science; Social Equilibria and Social Change,” Human Relations 1 (June 1947), 5-41.

3. Gloria J. Miller, Dagmar Bräutigam and Stefanie V. Gerlach, Business Intelligence Competency Centers: A Team Approach to Maximizing Competitive Advantage, SAS Institute (Hoboken, NJ: John Wiley & Sons, 2006).

4. Bill George, “Truly Authentic Leadership,” U.S. News & World Report, October 30, 2006.

5. Walter Brueggemann, The Prophetic Imagination, (Philadelphia: Fortress Press, 1978).

6. “On Being with Krista Tippet,” podcast, December 2011, https://onbeing.org/series/podcast/.

7. Diane Ackerman, An Alchemy of Mind: The Marvel and Mystery of the Brain (New York: Scribner, 2005).

8. John O. Mudd, “Build on Formation’s Powerful Experience,” Health Progress 98, no. 3 (May-June 2017): 63-67.

QUESTIONS FOR DISCUSSION How emerging leaders can find their place in Catholic health care is a concern as questions of identity and mission are highlighted in the changing world of health care and the need for transformation within the ministry. Tim Moran explores the formation of future and emerging leaders in light of our history and our future.

1. The intersections of COVID-19, an overdue reckoning with racial disparities and the economic and social disparities within the determinants of health have changed the landscape of health care and the expectations we have of leaders. What do you think this means for how we approach formation? What factors need to be emphasized and what new skills and practices need to be embedded?

2. Theologian Walter Brueggemann describes the prophets we know from the Hebrew scriptures as “poets and storytellers, who gave voice to a new way of seeing.” Are new leaders being introduced to mentors, tools and other resources to tap their own prophetic imaginations? How does that happen in your ministry? What additional sources and experiences could be added?

3. How can we better pursue the intersection of inner personal transformation (Who am I?) with the mission of Catholic health care organizationally (Who are we together?) How can our ministry support and energize formation practices for leaders who will be called upon to imagine future flourishing of the ministry?

4. Moran uses the image of serotiny and the example of the seeds of the lodgepole pine, which are only released and dispersed during the extreme heat and winds of a forest fire. He claims that serotinous leaders are those who allow themselves to be broken open and vulnerable during and after a crisis, so the seeds of new possibility and transformation can be released in themselves, for others and the organization. How does this statement make you feel? How willing are you as a leader to be that vulnerable?

What would make this easier for you? Does your system’s formation program help leaders to be vulnerable and transformed?

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Providence Holy Cross Outlines Steps for Ethical Distribution of a COVID Medication D.W. DONOVAN, D.Bioethics, and REX HOFFMAN, MD, MBA

P

rovidence Holy Cross Medical Center is a Level II trauma center located in the northern tip of Los Angeles. The hospital has a reputation for serving the community in the most difficult of situations, playing a major role in responding to disasters, from earthquakes and train crashes to school shootings and rampant fires.

Most recently, Holy Cross found itself in one of the COVID “hot spots,” consistently recording the highest census of patients with a diagnosis of COVID-19 among the 51 hospitals in the Providence St. Joseph Health system.

At the beginning of the COVID-19 pandemic, we knew that demand for critical medical supplies would far outstrip what was available. Nationally, the initial focus was on the availability of ventilators. However, attention soon turned to the availability and allocation of a drug called remdesivir, which had shown potential in early drug trials to improve outcomes in patients with COVID-19.

The Food and Drug Administration approved the use of remdesivir for patients under certain conditions and began distributing the limited supply.

On May 14, 2020, Providence Holy Cross Medical Center received its first allocation of remdesivir. The amount we were given was enough to treat, at most, four of the 61 COVID-positive patients that we were caring for at that time.

Following the recommendations of both the Providence Office of Theology and Ethics (the system’s office for ethics) and the California Department of Public Health, the leadership team at Providence Holy Cross Medical Center formed a clinical discernment team to wrestle with questions about the just and ethical allocation of a scarce resource. Participants included physicians from palliative care and infectious disease, as well

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as hospitalists, intensivists and clinicians from infection control, pharmacy, nursing, administration and ethics.

The team began our discussion with (and would revisit several times) an awareness that unconscious or implicit bias had the potential to cloud our process. To safeguard against potential bias, we sought to establish a set of inclusion and exclusion criteria that were grounded in the existing medical evidence. Much of these criteria were drawn from the guidelines provided by the California Department of Public Health1 and the initial findings of the remdesivir study.2 In order to be included in the pool of patients who might receive the medication, the patient must: 1. Be hospitalized with a positive test for COVID-19 virus.

2. Be over 18 years of age and not pregnant.

(Remdesivir was available to these patients through a separate “compassionate use” process.)

3. Have a Creatinine Clearance of > 30mL/min.

(Creatine clearance tests check renal function, or how well the kidneys work.)

4. Have ALT/AST levels < 5x the upper limit of normal. (The check of ALT/AST levels shows if a person has elevated alanine transaminase and/ or aspartate transaminase. Elevated liver enzymes often indicate inflammation or damage to cells in the liver.)

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Additionally, patients would be excluded from consideration if: 1. The patient is showing steady or significant improvement.

2. The patient is transitioning to a lower level of care.

3. The patient had a terminal diagnosis with less than six months to live.

To be clear, inclusion criteria did not automatically mean that the patient would receive the medication. While the discernment role was critical, the importance of an informed consent conversation between the attending physician and the patient or surrogate was equally important. Our Catholic health care system already had a strong commitment to honest and ongoing conversations with our patients regarding their goals of care, but this situation increased the necessity of such communications.

The clinical discernment team spent a significant amount of time discussing issues around quality of life and whether or not that should be a factor in discerning if the patient would be offered the medication. A review of the literature revealed a lack of consensus on this issue at the national level, with several articles raising concerns that quality of life measures might inadvertently discriminate against those with disabilities. Clearly, this is an area worth further discussion in search of a just and moral national consensus.

With our “screening process” established and the number of patients deemed most appropriate for the remdesivir treatment reduced from 61 to 34, our next task was to determine how we would select the patients who would be offered the treatment. The team agreed that a lottery system amongst those patients in a similar condition would be the best approach from both a clinical and ethical perspective.

To group our patients by similar condition, the clinical discernment team agreed upon three clinical variables that the preliminary research indicated were most critical in predicting outcome.

When assigning a score for each of these variables, the patients were evaluated by at least two physicians using objective criteria. The three vari-

ables considered were length of stay, a measurement of the level of oxygen in the patient’s blood, and the degree of inflammation as measured by a marker referred to as C Reactive Protein.

Variable

1 Point

2 Points

3 Points

Length of stay (days) Hypoxia (% FiO2) C Reactive Protein

> 10 < 40 At least 15

6–10 40–60 —

1–5 > 60

—

With the identifying factors blinded to the members of the clinical discernment team, we now had four patients with a score of six. Using the consent process described below, each of those four patients (or their surrogate decision-maker) was approached and offered the remdesivir treatment. Three of these four patients accepted the recommended plan of care, and were started on the remdesivir regimen, leaving us with enough remaining vials for a single patient.

Next, we considered the group of 10 patients who had a score of five. As noted above, we elected to use a lottery process that randomized this group of patients to establish the order in which they would be considered (we used random.org).

We then re-assembled the clinical discernment team and elected to review each of the cases with a twofold purpose in mind. First, a final review of the patient’s entire clinical condition seemed warranted before administering such a scarce resource. Just as importantly, we wanted to begin

The clinical discernment team spent a significant amount of time discussing issues around quality of life and whether or not that should be a factor in discerning if the patient would be offered the medication.

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refining our criteria for appropriateness so that it could be applied consistently to reduce bias and variation. As we reviewed each patient, we were acutely aware that each decision we made set the standard for future evaluations.

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Two patients had a history of failed attempts to extubate, combined with extremely poor kidney function. Two patients were not necessarily terminal (as defined by death being expected within six months) but had already decided to focus their efforts on comfort measures without additional escalation of care. This caused us to further refine our exclusion criteria. A fifth patient had improved significantly in the past 24 hours and was now on a path to discharge within 48 to 72 hours. The sixth patient appeared likely to benefit from remdesivir. That patient was offered and received the final regimen of the medication.

In the midst of so many medical experts and an overwhelming amount of articles in the medical journals, it seemed particularly important to engage with the patient or surrogate in a carefully crafted consent process. While some physicians and even systems have thought that administering remdesivir should fall under the general

consent as a part of the conditions of admission, our clinical discernment team felt strongly that an informed consent conversation was ethically critical.

Part of our process was influenced by requirements laid down by the FDA as conditions for receiving the drug. The FDA provided an information sheet that we were required to share with the patient/surrogate. It served to remind all of us that there was no vaccine for this virus and no cure. There was enough clinical evidence to suggest that remdesivir might help, but there was not sufficient evidence to provide any guarantees.

We were able to offer it only through a process whereby the FDA authorizes the use of a medication prior to the completion of clinical trials. This process is known as an Emergency Use Authorization (EUA).

Those requirements alone were consistent with a typical informed consent conversation.

INFORMED CONSENT TEMPLATE FOR ADMINISTRATION OF REMDESIVIR I am recommending the administration of remdesivir for this patient. I have verified that the patient is:

1. Covid-19 positive 2. 18 years of age or older1 3. Not pregnant2 4. SpO2 < 94% on room air or requiring supplemental oxygen or mechanical ventilation (SpO2 is a measurement of the level of oxygen saturation in the blood.)

5. Has a Creatinine clearance greater than or equal to 30 ml/min 6. LFT (liver function test) including an ALT/ AST levels less than 5x the upper limit of normal.

7. Not preparing to be discharged 8. Not on hospice or comfort care

The patient and/or their surrogate decision maker has been informed of the known and potential benefits of remdesivir as well as the purpose of and details related to the administration of this treatment. I have also explained that remdesivir is an unapproved drug that is authorized for use under the Food and Drug Administration’s Emergency Use Authorization. I have informed the patient/surrogate of the risks and benefits of and the alternatives to receiving this

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medication, including the option to refuse the medication and the risks of doing so.

No adequate and well-controlled studies of remdesivir use in pregnant women have been conducted. Remdesivir should be used during pregnancy only if the potential benefit justifies the potential risk for the mother and the fetus.

If the patient is pregnant, I have informed the patient that we have no information regarding the presence of remdesivir in human milk, the effects on the breastfed infant, or the effects on milk production. I have strongly encouraged the patient to suspend breast-feeding while taking this medication.

A copy of the Fact Sheet for Patients: Emergency Use Authorization (EUA) of Remdesivir for Coronavirus disease 2019 (COVID-19) has been reviewed with and provided directly to the patient or will be made available to the surrogate decision maker as soon as practicable.

NOTES 1, 2 Patients who were under the age of 18 or pregnant would be able to receive remdesivir directly from Gilead, the manufacturer of this drug, so they are excluded from receiving the medication provided to us under the Emergency Use Authorization (EUA).

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Beyond that, common sense and a respect for patient autonomy suggested that most people would want to have the opportunity to discuss options before having a drug that was untested and unapproved for general usage administered to them.

Recognizing that these were atypical informed consent conversations, we developed a standardized note that our physicians could access through our electronic medical record. This provided them with language that we believed would be helpful and reminded the physicians of the numerous requirements that were a part of the entire process. (For this article, the form has been amended slightly, with some additional details for readers.)

The very nature of responding to a pandemic makes a full review of any issue challenging. Our discussions raised several other issues that we recognize are worthy of additional reflection.

We name three of them here in the interests of advancing the conversation and inviting such reflection.

Dr. Ezekiel Emmanuel, in his article entitled “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” recommends that critical health care and infrastructure workers receive preference for scarce medical resources. While Providence St. Joseph Health ultimately discerned that our system would not include a preference for key workers as a factor in the discernment process, accepting this decision was difficult for some members of the clinical discernment team.

While every member was supportive of a commitment to care based on the patient’s clinical condition without regard to race, age, ethnicity or any other protected status, some were supportive of Dr. Emmanuel’s recommendation. We benefited from a well-articulated, ethically grounded statement from our system, but the lack of consensus on this issue at the national level was reflected by the passionate debate we experienced locally.

Should the patient’s pre-existing quality of life be a factor in determining who will receive scarce resources? If a patient could be returned to a quality of life that they had previously found to be acceptable, should that decision be subject to review in light of the scarce resources? Specifically, what are the benefits and risks of using such scales as the Eastern Cooperative Oncology Group (ECOG) or Sequential Organ Failure Assessment (SOFA)?

Given that intubated patients are recommended to receive twice the amount of remdesi-

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vir, should they be excluded from consideration in order to treat a larger number of patients? Or should they receive a higher priority because they are sicker? Is the priority to treat the most number of patients or to treat the sickest? What ethical rationale would ground either decision?

The COVID-19 pandemic highlighted the need for a discernment process that removed bias when selecting patients to receive a scarce resource such as remdesivir where demand outstrips supply. Such discernment is not unique to COVID-19; it will certainly become an issue in other scenarios when demand is greater than supply. Having objective criteria and an objective scoring system in place that has been agreed to by a representative group of clinicians will take some of the subjectivity out of the patient selection process.

The importance of having sound ethical counsel at the table to guide the conversation and ensure that the ministry as a whole remains true to its values cannot be underestimated. The hope is that our experience will provide some details and direction on how best to approach such difficult times. As we continue to learn from one another and from each situation we encounter, we must all continue to refine our practices, ensuring the best care for our patients and minimizing the moral distress of both the patient and all those at the bedside.

D.W. DONOVAN is chief mission integration officer at Providence Holy Cross Medical Center in Mission Hills, California. REX HOFFMAN is chief medical officer at Providence Holy Cross Medical Center and leader of the Southern California Clinical Institutes.

NOTES 1. John H. Beigel et al., “Remdesivir for the Treatment of Covid-19 - Preliminary Report,” The New England Journal of Medicine, May 22, 2020, https://www.nejm.org/doi/ full/10.1056/NEJMoa2007764.

2. California Department of Public Health, Remdesivir Public Distribution Fact Sheet, May 29, 2020, https:// www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID19/Remdesivir-Distribution-Fact-Sheet-.aspx.

ADDITIONAL INFORMATION: Fact Sheet for Patients and Parent/Caregivers: Emergency Use Authorization (EUA) of Remdesivir for Coronavirus Disease 2019 (COVID-19), Federal Drug Administration, https://www.fda.gov/media/137565/download.

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U.S. Postal Service (Required by 39 U.S.C. 3685) 11.

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Title of publication: Health Progress Publication number: 0882-1577 Date of filing: October 14, 2020 Issue Frequency: Quarterly No. of issues published annually: 4 Annual subscription price: free to members, $29 for nonmembers and foreign subscriptions Location of known office of publication: 4455 Woodson Rd., St. Louis, MO 63134-3797 Location of headquarters of general business offices of the publisher: 4455 Woodson Rd., St. Louis, MO 63134-3797 Names and complete addresses of publisher, editor, and managing editor: Catholic Health Association, Publisher; Mary Ann Steiner, Editor; Betsy Taylor, Managing Editor; 4455 Woodson Rd., St. Louis, MO 63134-3797 Owner: The Catholic Health Association of the United States, 4455 Woodson Rd., St. Louis, MO 63134-3797 Known Bondholders, Mortgagees, and Other Security Holders: None The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes has not changed during the preceding 12 months.

Upcoming Events from The Catholic

Health Association

Community Benefit 101 Virtual Meeting Oct. 27–29 |2 – 5 p.m. ET

Networking Call for Facility Ethicists

Oct. 22 | 2:30 – 3:30 p.m. ET

Global Health Networking Event

13. Publication name: Health Progress 14. Issue date for circulation data below: Fall 2020

Nov. 4 | 3:30 – 4:30 p.m. ET Average No. Copies Each Issue During Preceding 12 Months

15. Extent and nature of circulation: a. Total no. copies (net press run) b. Paid and/or requested circulation (1) Paid/requested outside-county mail subscriptions stated on Form 3541 (2) Paid in-county subscriptions (3) Sales through dealers and carriers, street vendors, counter sales, and other USPS paid distribution (4) Other classes mailed through the USPS c. Total paid and/or requested circulation [sum of 15b (1), (2), (3), and (4)] d. Free distribution by mail (Samples, complimentary, and other free) (1) Outside-county as stated on Form 3541 (2) In-county as stated on Form 3541 (3) Other classes mailed through the USPS (4) Free distribution outside the mail (Carriers or other means) e. Total free distribution (sum of 15d (1), (2), (3), (4) ) f. Total distribution (Sum of 15c and 15e) g. Copies not distributed h. Total (sum of 15f and g) i. Percent paid and/or requested circulation (15c divided by 15f times 100) 16. This statement of ownership will be printed in the Fall 2020 issue of this publication.

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I certify that the statements made by me above are correct and complete.

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Mission Leader Competency Webinar

Nov. 5 | 1:30 – 3 p.m. ET

2020 Mission Leader Virtual Seminar: Our Competencies in Today’s Context

Nov. 17–18 | 1–5:30 p.m. ET each day

Mission in Long-Term Care Networking Call Dec. 15 | 3 p.m. ET Members only

Human Trafficking Networking Call December 16 | Noon ET

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MISSION

REIMAGINING OUR MINISTRY

W

e have all heard the saying, “The only thing certain in this world is change.” Whether that change occurs slowly over time or in sudden and abrupt spasms may vary, but it will happen. Over the past months, Catholic health care has experienced rapid change as a result of the pandemic and the resulting ripple effects in virtually every aspect of society. In the midst of this chaos, our ministry is undergoing a significant transformation.

Fortunately, one of the key tenets of chaos theory is that when you stand back and look at the larger picture, there is inevitably a pattern that emerges from that apparent chaos, a common thread that is visible when one takes the longer view.

Catholic health care systems across the country are engaged in challenging and rigorous conversation regarding the future of the ministry “post-COVID” and how it will affect our ministries, values and Catholic identity.

The challenge is how to adapt DENNIS and transform in a manner that GONZALES will increase the potential for meeting the needs of the day (short-term survival), foster future viability (long-term sustainability), and meet the expectations of sponsors, church hierarchy, boards, associates, patients and the community as a whole. It is a fine line that we must walk in order to keep a healthy balance where the ministry can maintain its mission-focused identity and be structurally and strategically prepared to thrive in a rapidly changing health care industry. A significant question for leadership, then, is how can we support and facilitate the attitudinal change that must occur if the health care paradigm is to evolve? I would suggest that there are two powerful forces we already possess as a ministry to help us accomplish this monumental task, a common thread if you will: ministry formation and the legacy we have been given by those who went before us and weathered similar or worse storms over the centuries.

I have tremendous respect for the vital work our formation leaders do across the ministry.

Their goals are lofty, complicated and difficult to measure. Educators have traditionally separated instructional outcomes into three domains — cognitive, psychomotor and affective — with the

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cognitive domain dealing with thinking, the psychomotor domain with the physical, and the affective domain with feelings.1 The cognitive domain primarily concerns how people learn and how to build educational strategies that are compatible with a person’s preferred learning style. The psychomotor domain stresses the importance of repetition and procedural learning and is mainly concerned with behavior. Finally, the affective domain focuses on the feelings and attitudes of the learners.

It is with the affective domain that we are primarily concerned when addressing the challenge of transformational learning for individuals and organizations throughout the ministry. Fortunately, ministry and leadership formation programs are uniquely designed to tap into, challenge and “form” the intrinsic spiritual, philosophical and motivational characteristics of the participants.

Clearly, this is no easy task, but suffice it to say that if we are successful in our formation programs, then true transformation can occur at the individual and organizational level. When attitudes are changed in their deepest sense, knowledge is enhanced and behaviors change. Our leaders, board members, physicians and staff will approach their work not as a job but as a vocation, a sacred calling to be a part of something bigger than themselves.

They become people who can take the longer view of the ministry, beyond the crisis of the day.

After all, isn’t taking the “long view” precisely the heritage that our ministry is built upon? In a conversation recently with a sister from a sponsoring congregation, I asked her how their health system was weathering the current storm. Her rather matter-of-fact response was, “This may be

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It may seem somewhat of a paradox that we new to us, but it’s not new for the ministry. We’ve been here before, we’ll get through it, and we’ll be fall back on the most fundamental aspects of our stronger for it.” As I reflected on that conversation, ministry at a time when radical change and an I increasingly felt a sense of hope and confidence openness to transformation are needed in order about the future of Catholic health care. Most of to ensure long-term relevance and sustainability. our systems were founded in response to epidem- My suggestion is that it is precisely during chaotic ics that devastated our communities over the past times that we remember what it was that allowed 150-plus years. Small, dedicated and determined us to reinvent ourselves and thrive historically. groups of primarily women religious came to the Only a well-formed and inspired work force comUnited States in order to care for those most in bined with a willingness to do what is necessary need. From those humble beginnings, the Catho- in order to achieve our mission will create the lic health care ministry has thrived (through wars, space to reimagine what is possible. We have done depressions, recessions, racial and political strife, it before, and we can do it again. This is but one amazing advances in technology and medicine, chapter in our long history, and our time on this Vatican I and II, etc.) and become the tremendous stage is but a fleeting moment. What will we do force that it is today: the largest group of nonprofit with the short time we have?

One of my personal heroes, St. Archbishop health care providers in the nation.

How did this happen? By the grace of God, Oscar Romero, put it beautifully, “We cannot do dedicated people, servant leaders and a willing- everything, and there is a sense of liberation in ness to reinvent ourselves — to reimagine how we realizing that. This enables us to do something, can live out our mission. We have undergone transformations many Only a well-formed and inspired work times over these past centuries, force combined with a willingness reading the signs of the times and adapting to meet the current needs. to do what is necessary in order to To be sure, we didn’t ask for or invite the transformation. It is almost achieve our mission will create the always the case that true transforspace to reimagine what is possible. mation occurs because of some crisis or disorienting dilemma that is followed by critical reflection.2 The circumstance and to do it very well. It may be incomplete, but is thrust upon us and is never easy or comfortable. it is a beginning, a step along the way, an opporIn the midst of crisis, we are forced to reexamine, tunity for the Lord’s grace to enter and do the question and reimagine how we operate, provide rest. We may never see the end results, but that is the difference between the master builder and services and are structured.

I can recall many instances when such a re- the worker. We are workers, not master builders; examination resulted in change or restructuring ministers, not messiahs. We are prophets of a fuof the ministry, and someone would say that “we ture not our own.” are not staying true to our mission.” My response: the mission (why we exist) is forever; it doesn’t DENNIS GONZALES, PhD, is senior director, mischange. It is to continue Jesus’ mission of love sion innovation and integration, Catholic Health and healing in the world. Ministries are a means Association, St. Louis. to fulfill our mission, and they do change — they are formed, grow, adapt and sometimes fade. How NOTES many services do we still provide today that we 1. Malcolm L. Fleming and W. Howard Levie, Instrucprovided 10, 20 or 50 years ago? Now, try to imag- tional Message Design: Principles from the Behavioral ine what our ministries will look like in the next and Cognitive Sciences (Englewood Cliffs, NJ: Educa10, 20 or 50 years! Our mission will be the same. tional Technology Publications, 1993).

How we live that mission will be transformed, yet 2. Jack Mezirow, Learning as Transformation: Critical again. It must. The alternative is stagnation at best Perspectives on a Theory in Progress (San Francisco, CA: and failure at worst. And that’s not who we are.

Jossey-Bass, 2000).

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COMMUNITY BENEFIT

COMMUNITY HEALTH NEEDS ASSESSMENTS DURING COVID NOT MISSION IMPOSSIBLE

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s of this writing, the Internal Revenue Service has twice delayed deadlines for filing required community health needs assessments (CHNAs). With later deadlines looming, community benefit leaders are proceeding to plan and carry out their next assessments and implementation strategies.

JULIE TROCCHIO

What at first looked like an impossible task because of working from home orders, prohibitions against public gatherings, overworked health departments and the need to address current conditions, conducting CHNAs is proving to be doable because of commitment to community wellbeing, building on prior work and a healthy dose of creativity.

DRIVEN BY MISSION

This is no time to ignore community need, say community benefit leaders. In some communities, over half of their residents have lost jobs and more have had their hours, and pay, reduced. The most vulnerable in our communities have become more vulnerable — people of color, immigrants and homeless people. Social needs, such as food and housing insecurity, seen before the pandemic are even more widespread.

With the need comes the will. With the will the way.

BUILDING ON PRIOR WORK

Community benefit leaders report that their best tools in addressing needs at this time are the partnerships they developed during past CHNAs. The CHNA process involves multiple organizations as they prioritize needs and plan for how to best address them. Relationships with community organizations, public agencies, faith-communities and others close to the pulse of communities are excellent sources of information about what is happening now. Town halls and focus groups may not be possible, but phone calls, virtual interviews

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with key informants and, of course, Zoom meetings allow community benefit leaders to gather information needed to plan for addressing needs.

The other valuable tool is the information collected during the last CHNA. One community benefit leader told CHA, “if access to care, mental health, food insecurity and housing were found to be significant needs in the last CHNA, it is a good bet that they are still problems, only more so with new populations.”

GOING WHERE THE NEED IS

To determine immediate needs as well as information needed for CHNAs, community benefit leaders can go to and turn to what may be new sources: homeless shelters, libraries, grocery stores. The voice of the community may be loud if we listen.

Key informants with current knowledge may be found in housing authorities, elected leaders, university researchers, local social service providers and 2-1-1 offices.

PUBLIC HEALTH DEPARTMENT RELATIONSHIPS ARE IMPORTANT

The pandemic has put many health departments, already strained, in overworked, overstretched circumstances. Still, keeping up with public health contacts can result in valuable input for the needs assessment and for developing collaborative strategies for addressing the public health crisis. Hospitals can also use this time to plan with public health officials to advocate for more resources to build up public health infrastructure.

RACIAL INEQUITY

While prior work and prior relationships can be helpful in the next round of needs assessments,

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community benefit leaders agree that there is urgency for addressing racial inequality and looking at the root cause of health problems. Recent events, such as the death of George Floyd, have revealed long-standing structural and systemic racism that has contributed to health disparities.

Many hospitals are looking internally at their own role in perpetuating racism. They are also forging new relationships with community partners that can help them understand and begin to address local problems. This may mean delving into issues outside of the health arena such as education, food, transportation, employment and housing policies.

WHAT THE VIRUS HAS TAUGHT US

to the public The rules go on to say what must be described in the written CHNA report: Definition of the community served Description of the methods used to conduct assessment Description of who the organization worked or contracted with Description of how the hospital solicited required input Written comments received on most recent CHNA and assessment and implementation strategy Criteria used in identifying significant, prioritized needs Description of the resources available to address health needs Evaluation of the impact of actions since the previous CHNA

Researchers tell us that people who are older, have pre-existing heart and respiratory problems, are obese and/or use tobacco are at higher risk of contracting the coronavirus. This suggests that traditional community Many hospitals are looking internally benefit activities such as screening, early detection and intervention at their own role in perpetuating for these issues are more important racism. They are also forging new than ever.

The virus has also shown us relationships with community the power of collaboration — with other hospitals, with public health partners that can help them and with other organizations. It understand and begin to address has shone a bright beam on the importance of root causes, especially local problems. structural racism. It has amped up creativity as hospitals and their partners have had to learn to find new solutions and The IRS rules do not say we must produce new ways of working together. academic-style papers with multiple tables and charts; they do not require hiring expensive contractors or full-time researchers. They do not NEED TO PIVOT? Some hospitals are likely to modify their CHNA require reporting that all planned activities were from prior years. To do so, it is important to real- carried out and were successful.

The purpose of IRS requirements is transparize what is legally required for community health ency: let the community know you are aware of needs assessments and what is not. its needs, are working with partners to prioritize IRS rules require hospitals to: Define the community and address those needs and what progress is be Assess the health needs of the community ing made.

Solicit and take into account input from the That we can do. community and public health Document the CHNA in a written report ap- JULIE TROCCHIO, BSN, MS, is senior director of community benefit and continuing care at the proved by an authorized body Make the CHNA report widely available Catholic Health Association, Washington, D.C.

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POLICY

MEDICARE’S REGULATORY RESPONSE TO THE COVID-19 CRISIS KATA KERTESZ, JD

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n early 2020, the rapidly spreading novel coronavirus and its associated deadly disease, COVID-19, drastically altered the health care delivery system in the United States. In March 2020, the President declared a national emergency. This declaration, coupled with the nationwide public health emergency declaration from the Secretary of Health and Human Services in January, triggered new flexibilities for the Centers for Medicare & Medicaid Services (CMS) to address the pandemic in the Medicare program. In the subsequent weeks, CMS issued numerous Public Health Emergency (PHE)-related rules, waivers and guidance.

As of this writing, Congress has passed four bills relating to the COVID-19 crisis.1 While there are some Medicare coverage provision changes in the four bills, most of the Medicare-related changes have been issued by CMS through regulation and sub-regulatory guidance.2 This article focuses on CMS’s regulatory response to the crisis, highlighting a few of the most important changes: expansion of telehealth services; waivers of statutory and regulatory requirements for nursing facilities; and coverage for COVID-19 testing.

The Center for Medicare Advocacy has compiled, and continues to update, a comprehensive catalogue of the wide-ranging changes in the Medicare program during the pandemic, available at https://medicareadvocacy.org/covid-19-anadvocates-guide-to-medicare-changes/.

While most of the Medicare-related changes are retroactive to March 1, 2020, and will last until the Public Health Emergency related to the COVID-19 crisis is lifted,3 this article examines changes, including those that are likely to be extended.

TELEHEALTH SERVICES

Early data suggests that COVID-19 is particularly harmful for older adults.4 As a result, much of CMS’s regulatory flexibility has been aimed at practical ways to remove barriers to urgent and necessary health care, while minimizing potential exposure of older adults to the virus. Therefore, one of the chief Medicare policy changes re-

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sponding to the pandemic is the broad expansion of coverable telehealth services.

During the health emergency, CMS is permitting Medicare beneficiaries to receive coverage for a wider range of health care services without having to travel to a facility. CMS accomplished this by waiving a number of requirements in order to expand the list of providers who can offer telehealth services during the emergency.5 This has been accomplished by permitting routine visits, preventive health screenings for cancer and other illnesses to be included in telehealth,6 and by providing payment parity for telehealth.7 More than 80 additional services are covered by Medicare when furnished via telehealth, including emergency department visits, initial nursing facility and discharge visits, and home visits.8 During the pandemic, telehealth has been critical in limiting disruptions in care while protecting beneficiaries from the spread of the deadly virus.

CMS has signaled that it intends to make many of the Medicare telehealth changes permanent after the conclusion of the current crisis.9 There is also widespread support in Congress for expanding telehealth benefits.10 Given the likelihood of continued telehealth expansion, future policy proposals should stress that telehealth cannot replace face-to-face visits; rather, telehealth should be considered an important complementary tool to in-person services.

One concern with increasing reliance on tele-

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health as a substitute for personalized in-person of skilled nursing facilities (SNF). For individuservices is that it could exacerbate existing health als affected by COVID-19, CMS has waived the disparities, many of which were starkly exposed requirement that a patient must first have spent at by the pandemic. Early COVID-19 research and least three consecutive days as an inpatient in an data suggest a correlation between low incomes, acute-care hospital in order for Medicare Part A communities of color and risks of illness and se- to pay for a patient’s subsequent stay in a skilled verity of illness.11 nursing facility.17 Many underserved beneficiaries do not have While CMS cannot make this waiver permareliable broadband and have limited, if any, access nent without legislation, CMS does have the auto digital literacy training and remote technolo- thority and discretion under the Medicare statute gies. Access to reliable internet must be factored to count all time in the hospital — including time into telehealth policy. 12 Additionally, difficulty hearing well HIPAA privacy protections, which have enough to use a telephone, even with hearing aids, along with largely been suspended for telehealth difficulty seeing well, difficulty interactions between patient and speaking, and limited English proficiency are all factors that could provider during the pandemic, must jeopardize health outcomes when 13 care is only provided virtually. apply to such interactions. Personal Any expansion of telehealth health data must also be kept secure. must ensure privacy and data security for personal health information. HIPAA privacy protections, which spent in “observation status” — toward the threehave largely been suspended for telehealth in- day stay requirement.18 A large coalition of conteractions between patient and provider during sumer and patient advocates, along with health the pandemic,14 must apply to such interactions. care providers, support CMS exercising this authority to allow greater access to skilled nursing Personal health data must also be kept secure.15 Additionally, expanding telehealth must not facility coverage beyond the pandemic.19 be used as a means to further weaken Medicare Despite the broadening access to SNF benefits Advantage network adequacy requirements. resulting from the CMS waiver, many other CMS CMS has already begun this process by allowing waivers have limited beneficiary protections for Medicare Advantage plans to meet weaker net- nursing home residents during this pandemic. work standards if they provide certain services CMS suspended certain reporting requirements, via telehealth.16 This essentially allows plans to residents’ rights, nurse aide training rules and ma“count” certain telehealth availabilities toward ny oversight activities that are designed to protect the standard of how many providers are within nursing home residents.20 In addition, in the abthe time and distance required for a large per- sence of federal leadership, nursing facilities have centage of their enrollees. Unfortunately, the end been in competition with each other for tests and result of weakened network requirements is that personal protective equipment.21 These factors, as beneficiaries may end up having to pay more for well as low staffing levels in many facilities, and out-of-network providers when they cannot find infection control issues, have led to massive outan accessible provider in their plan’s network of breaks in facilities. providers.

The COVID-19 pandemic has resulted in a staggeringly large number of deaths in nursing facilities. As of September 2020, over 80,000 SKILLED NURSING FACILITIES During the public health emergency, CMS has ap- deaths from COVID-19 occurred in long-term proved a waiver that expands Medicare coverage care facilities, which include nursing care facili-

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ties, amounting to over 41% of COVID-19 deaths in the United States.22 In order to address these issues, CMS must fully reinstitute Requirements of Participation23 as well as survey and enforcement activities that have been waived during the pandemic. CMS must also require nursing facilities to be transparent about COVID-19 infection and staffing levels in the nation’s nursing facilities retroactive to January 2020. A coordinated federal response for personal protective equipment and expanded testing for staff and residents is also essential.

CONCLUSION

CMS responded to the catastrophic and rapidly spreading COVID-19 pandemic with various waivers to regulations in the Medicare program. The pandemic waivers limited disruptions in care and provided expanded benefits in some cases, but also suspended some crucial beneficiary protections. Some waivers, such as expansions in telehealth, are likely to continue after the pandemic.

KATA KERTESZ is policy attorney at the Center for Medicare Advocacy, Washington, D.C.

COVERAGE FOR COVID-19 TESTING

CMS guidance ensures broad coverage for COVID-19 testing. Testing is covered with no costsharing in both traditional Medicare and Medicare Advantage plans. During the current pandemic, CMS also waived the requirement that there be a doctor’s or other provider’s written order, allowing tests to be covered when ordered by a broad range of health care professionals.24 In keeping with CMS’s objective to minimize person-to-person contact during the pandemic, Medicare is authorized to pay laboratory technicians to travel to a beneficiary’s home to collect a specimen for COVID-19 testing, eliminating the need for the beneficiary to travel to a health care facility for a test.25 Medicare Part B also will cover beneficiary cost-sharing for provider visits during which a COVID-19 diagnostic test is administered or ordered.26 Medicare Advantage plans must provide coverage for COVID-19 diagnostic testing, including the associated cost of the visit, in order to receive testing at no cost to the beneficiary.27 CMS also temporarily relaxed rules so that Medicare Advantage plans can expand benefits, add additional benefits and institute more generous costsharing.28 This allows plans to waive or reduce enrollee cost-sharing for COVID-19 treatment and address issues or medical needs raised by the outbreak, such as covering meal delivery or medical transportation services.29 Additionally, if a COVID-19 vaccine is developed, it will be covered under Part B with no cost-sharing.30 CMS should extend the broad coverage of testing for COVID-19 in order to keep the virus under control, even if the public health emergency declaration is ended.

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NOTES 1. On March 6, 2020, the President signed into law the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, H.R. 6074, 116th Cong. (2020) (sometimes referred to as COVID Bill #1); On March 18, 2020, the President signed into law the Families First Coronavirus Response Act, H.R. 6201, 116th Cong.

(2020) (COVID Bill #2); On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act, H.R. 748, 116th Cong.

(2020) (COVID Bill #3); On April 24, 2020, the President signed into law the Paycheck Protection Program and Health Care Enhancement Act, H.R. 266, 116th Cong.

(2020) (referred to as an interim emergency funding package).

2. See CMS’ webpages devoted to the COVID crisis: https://www.cms.gov/About-CMS/Agency-Information/ Emergency/EPRO/Current-Emergencies/CurrentEmergencies-page and https://www.cms.gov/outreach-education/partner-resources/coronavirus-covid19-partner-toolkit. CMS’ list of their ongoing waivers: https://www.cms.gov/files/document/summary-covid19-emergency-declaration-waivers.pdf. On April 6, 2020, CMS published an Interim Final Rule (hereinafter referred to as the IFR), at 85 F.R. 19230 (April 6, 2020), https://www.govinfo.gov/content/pkg/FR-2020-04-06/ pdf/2020-06990.pdf. On May 8, 2020, CMS published another Interim Final Rule (hereinafter referred to IFR 2) at 85 F.R. 27550 (May 8, 2020), https://www.govinfo. gov/content/pkg/FR-2020-05-08/pdf/2020-09608.pdf.

3. CMS, “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers,” https://www.cms. gov/files/document/summary-covid-19-emergencydeclaration-waivers.pdf.

4. CDC, “COVID-19 Guidance for Older Adults,” https:// www.cdc.gov/aging/covid19-guidance.html.

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5. CMS, “Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19” (updated April 29, 2020), https://www.cms.gov/files/document/covid-19physicians-and-practitioners.pdf. Previously, covered telehealth only included services provided by doctors, nurse practitioners, clinical psychologists and licensed clinical social workers. CMS has waived a number of requirements to include “all those that are eligible to bill Medicare for their professional services. As a result, a broader range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth to provide many Medicare services.”

6. CMS, “Physicians and Other Clinicians.”

7. CMS, “President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak,” https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicarebeneficiaries-during-covid-19-outbreak.

8. See, for example, CMS memo “Medicare Telemedicine Health Care Provider Fact Sheet,” March 17, 2020, https://www.cms.gov/newsroom/fact-sheets/ medicare-telemedicine-health-care-provider-fact-sheet.

Please note that telehealth services are distinguished from brief communications or “virtual check-ins,” which are short patient-initiated communications with a health care practitioner, and e-visits, which are non-face-toface patient-initiated communications through an online patient portal.

9. Casey Ross, “‘I Can’t Imagine Going Back’: Medicare Leader Calls for Expanded Telehealth Access after Covid-19,” Stat, June 9, 2020, https://www.statnews.com/2020/06/09/ seema-verma-telehealth-access-covid19/.

10. Mohana Ravindranath, “Senators Push for Permanent Telehealth Changes,” Politico, June 15, 2020, https://www.politico.com/newsletters/morningehealth/2020/06/15/senators-push-for-permanenttelehealth-changes-788506.

11. See, for example, Center for Medicare Advocacy Weekly Alert, “Research: Low-Income and Communities of Color at Increased Risk From COVID19,” May 21, 2020, and citations therein, https:// medicareadvocacy.org/research-low-income-andcommunities-of-color-at-increased-increased-riskfrom-covid-19/ and Ways & Means Committee, Chairman Richard Neal, “The Disproportionate Impact of COVID-19 on Communities of Color,” https:// waysandmeans.house.gov/legislation/hearings/ disproportionate-impact-covid-19-communities-color-0.

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12. July 2020 Congressional Report, “Left Out: Barriers to Health Equity for Rural and Underserved Communities Report of the Committee on Ways and Means Majority U.S. House of Representatives,” https://waysandmeans. house.gov/sites/democrats.waysandmeans.house. gov/files/documents/WMD%20Health%20Equity%20 Report_07.2020_FINAL.pdf ; see also The New York Times, “Is Telemedicine Here to Stay?” Aug. 3, 2020, https://www.nytimes.com/2020/08/03/health/covidtelemedicine-congress.html?smid=tw-nythealth& smtyp=cur 13. Judy George, “Telehealth Boom Misses Older Adults,” MedPage Today, Aug. 4, 2020, https:// www.medpagetoday.com/practicemanagement/ telehealth/87901?xid=nl_mpt_DHE_2020-0805&eun=g1439001d0r&utm_source=Sailthru&utm_ medium=email&utm_campaign=Daily%20Headlines%20Top%20Cat%20HeC%20%202020-0805&utm_term=NL_Daily_DHE_dual-gmail-definition.

14. HHS Office of Civil Rights, “OCR Issues Bulletin on Civil Rights Laws and HIPAA Flexibilities That Apply During the COVID-19 Emergency,” March 28, 2020, https:// www.hhs.gov/about/news/2020/03/28/ocr-issuesbulletin-on-civil-rights-laws-and-hipaa-flexibilities-thatapply-during-the-covid-19-emergency.html.

15. Nicol Turner Lee, Jack Karsten and Jordan Roberts, “Removing Regulatory Barriers to Telehealth Before and After COVID-19,” The Brookings Instiution and The John Locke Foundation, May 6, 2020, https://www.brookings. edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/.

16. 85 F.R. 33796 (June 2, 2020), Medicare Program; Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program, https://www.federalregister.gov/documents/2020/06/02/2020-11342/medicare-programcontract-year-2021-policy-and-technical-changes-tothe-medicare-advantage-program.

17. Requirement at 42 U.S.C. §1395x(i); waiver, https:// www.cms.gov/files/document/covid19-emergencydeclaration-health-care-providers-fact-sheet.pdf; see also https://www.cms.gov/files/document/se20011.pdf.

18. See generally, Center for Medicare Advocacy, “Outpatient Observation Status,” https://medicareadvocacy. org/medicare-info/observation-status/; “Observation Status Deprives Medicare Beneficiaries of Their Skilled Nursing Facility Benefit. Period.,” https://medicare advocacy.org/observation-status-deprives-medicarebeneficiaries-of-their-skilled-nursing-facility-benefit-

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period/. Also, a federal district court recently found that certain beneficiaries have the right to appeal their coverage as “observation status” hospital patients to Medicare. Alexander v. Azar, __ F. Supp. 3d __, 2020 WL 1430089 (D. Conn. 2020), appeal filed (2d Cir. May 22, 2020) (No. 20-1642). For more information see https:// medicareadvocacy.org/litigation/active-cases/.

19. Center for Medicare Advocacy, “Observation Stays Fact Sheet,” https://www.medicareadvocacy.org/wpcontent/uploads/2017/09/Observation-Coalition-FactSheet.pdf.

20. More information is available at https://medicareadvocacy.org/cmas-toby-edelman-testifies-at-congressional-hearing-on-covid-in-nursing-homes/.

21. Danielle Brown, “Providers Appeal to VP to Investigate PPE Distribution ‘Failures’; Senate Subcommittee Holds Hearing on Pandemic’s Impact on Nursing Homes,” McKnight’s Long-Term Care News, June 12, 2020, https://www.mcknights.com/news/providersappeal-to-vp-to-investigate-ppe-distributions-failuressenate-subcommittee-holds-hearing-on-pandemicsimpact-on-nursing-homes/; See also Neville M. Bilimoria, “More Equipment and Less Liability for COVID-19, Please!,” McKnight’s Long-Term Care News, April 4, 2020, https://www.mcknights.com/blogs/guestcolumns/more-equipment-and-less-liability-for-covid19-please/; see also Jordan Rau, “Nursing Homes Run Short of COVID-19 Protective Gear as Federal Response Falters,” NPR, June 11, 2020, https://www.npr.org/ sections/health-shots/2020/06/11/875335588/ nursing-homes-run-short-of-covid-19-protectivegear-as-federal-response-falters.

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22. Kaiser Family Foundation, “State Data and Policy Actions to Address Coronavirus,” September 24, 2020, https://www.kff.org/health-costs/issue-brief/ state-data-and-policy-actions-to-address-coronavirus/.

This number could be higher, as CMS only required nursing facilities to report COVID-19 deaths and problems since May 8, not since the beginning of the pandemic: IFR 2, Page 27601-02.

23. 42 C.F.R § 483.11-483.95 24. IFR 2, Page 27555.

25. IFR, Page 19258.

26. Note: this does not mean that all COVID-related treatment is covered without cost sharing. According to CMS, “cost-sharing does not apply for COVID-19 testingrelated services, which are medical visits that: are furnished between March 18, 2020 and the end of the Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of [certain] categories of HCPCS evaluation and management codes.”

27. CMS Memo, April 21, 2020, https://www.cms.gov/ files/document/updated-guidance-ma-and-part-d-plansponsors-42120.pdf.

28. “CMS Memo, April 21, 2020.”

29. “CMS Memo, April 21, 2020” 30. Section 3713 of Coronavirus Aid, Relief, and Economic Security (CARES) Act, H.R. 748, 116th Cong.

(2020), https://www.congress.gov/bill/116th-congress/ house-bill/748/text.

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ETHICS

LESSONS FROM SMALLPOX

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pproximately 40 years ago, the World Health Assembly adopted a resolution declaring the accomplishment of a global goal. Smallpox had been eradicated. This was a significant achievement, as the disease had been a devastating part of our human experience for thousands of years.

This achievement took place the technique safer, to demonstrate its scienabout 200 years after Edward tific effectiveness and to promote the technique, Jenner’s vaccine experiment, spreading its use. when the English doctor made There are some initial lessons that we can take discoveries that inoculation from Jenner’s work. Jenner experimented with incould provide protections from jecting cowpox into a test subject, James Phipps, the illness. So, the discovery of a the 8-year old son of his gardener. One scholar vaccine did not immediately re- Blake Edward DeLeon, has defended this action sult in defeating the disease. The as being moral in the time that the decision was BRIAN journey from global pandemic made, because inoculation, while not a common KANE to eradication offers some ethi- practice, was being used to develop immunity.4 cal lessons as we grapple with From our perspective today, it is clear that the current pandemic, COVID-19. we would not reach the same conclusion. It was Most of us are familiar with the general story common practice in Jenner’s time to use slaves, of Jenner’s discovery of a vaccine. He knew that children and prisoners as test subjects for medical dairymaids who were infected by cowpox devel- experimentation. Among the developments in the oped a natural immunity to smallpox. So, he found ethical considerations of clinical trials in the past a young woman, Sarah Nelms, who had open le- century, safeguards have been established to prosions from cowpox and transmitted the pus in her tect children and other vulnerable persons from wounds to his test subject. Although there were any research that would not offer some expected some reactions to the infection, these were short tangible benefit to them. To be fair to DeLeon, he lived, and upon recovery the person was immune to smallpox.1 Jenner is often unIn the past century, ethicists have derstood to be the founder of immunology. rightly condemned the misuse of Medical historians, though, have a power by health care personnel much more nuanced understanding of the origins of immunization and Jentoward patients and subjects ner’s role. He was not the first to note the connection between cowpox and smallwho lack the ability to protect pox, nor was he the first to deliberately themselves. inoculate in order to prevent smallpox.2 In the century prior to Jenner’s use of cowpox to inoculate against smallpox, physicians does argue that the second inoculation of smalldeliberately infected patients with smallpox to es- pox was consistent with the accepted practice of tablish immunity. Jenner was himself inoculated trying to mitigate the disease. There is a confusion with smallpox when he was eight years old and, here between culpability and immorality. One can by a contemporary’s account, the experience was say that someone who acted immorally may not quite horrible.3 Jenner’s contribution was to make be morally responsible because of ignorance. But,

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However, over time, it lost its strength to create that will never make an immoral act good.

The initial injection of cowpox was experi- a lifelong immunity to smallpox. Another drawmental; it was not clear that it was for the good of back was that this method sometimes also transthe patient. There was a hope, certainly, but hopes mitted other diseases, like syphilis.

The next step to the eradication of smallpox and experiments are categorically different. To mistake the one for the other is to create the con- was to develop a stable, effective and reproducditions for an abusive relationship between the ible vaccine. In 1840, Giuseppe Negri of Naples, Italy, created larger and more effective quantities researcher and the subject.

In short, in the past century, ethicists have of the vaccine by infecting calves with cowpox. rightly condemned the misuse of power by health The technique became known as animal vaccicare personnel toward patients and subjects who nation. It was used more widely after it was dislack the ability to protect themselves. The Tuske- cussed at a medical congress in France in 1860. gee Syphilis Trials, the Nazi medical experiments, and the Willowbrook HepatiMedicine has often depended tis Trials are representative of instances upon international cooperation where experimental subjects were used as a means to an end, rather than being and collaboration. It is essential treated as persons with human dignity.

Of course, in judging the choices to work together to control and made over two centuries ago, there eradicate a disease like COVID-19. should be a measure of consideration given to the culture of the time. Nevertheless, from the contemporary vantage point, in- Eventually, “vaccination parks” in Europe, and jecting the child of a servant with an experimental “vaccine farms” in the U.S. produced sufficient substance was immoral. We cannot let the hope of quantities of the vaccine. These facilities were a reward lead down a path where we use others to not regulated as was typical in medical practice at achieve what is a worthy goal. So, we may say that the time, and contaminated vaccines led to a numthis is an instance where there was no culpability, ber of deaths.6 Some governments began vaccine but certainly there was immorality. safety and quality control measures in the early Today, with the challenges of COVID-19, it is 20th century. essential that we maintain ethical guidelines reWyeth Laboratories created the modern vacgarding testing. So far, pharmaceutical companies cine with Dryvax, a freeze-dried vaccine in the have issued broad appeals for test subjects. We 1950s. This enabled the production of a heat-stamust not place the burden of testing on disadvan- ble vaccine that could be stored without refrigtaged persons or communities. We all might want eration. With that innovation, it became possible to consider if we’re able to volunteer, to ensure to begin to eradicate smallpox. The first goal was that a wide and equitable population of people are to eliminate the disease from the Americas. Then part of the trials. the World Health Organization called for a global Jenner did succeed in bringing the medical program beginning in 1958.7 community together to support his research and The eradication of smallpox would not have program to inoculate cowpox to prevent small- happened without the work of many people who pox. The challenge was to obtain enough of the perfected techniques and even instruments, like vaccine derived from cowpox to inoculate. There the bifurcated needle, that made mass immunizawas simply not enough of the vaccine available. tions possible. Medicine has often depended upHe often mentioned his frustration at not being on international cooperation and collaboration. It able to supply colleagues who asked him for the is essential to work together to control and eradirequisite vaccine.5 Human to human transmis- cate a disease like COVID-19.8 A global pandemic sion of cowpox came to be called the Jennerian requires a global response that does not set one technique, and it was used for the next 90 years. nation against another.

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We also should not assume that speed to develop an effective COVID-19 vaccine or vaccines is the hallmark of an effective response to this pandemic. The talk of an effective and safe vaccine for the public in the relatively short time frame of one year may place short-term considerations over long-term benefit. Let’s not place hubris above hope and safe scientific inquiry. To do so would be to ignore the lessons from the work of Edward Jenner, and the many, many people who have helped to eradicate one of the world’s worst diseases.

BRIAN M. KANE, PhD, is senior director of ethics for the Catholic Health Association, St. Louis.

NOTES 1. Stefan Reidel, “Edward Jenner and the History of Smallpox and Vaccination,” Proceedings 18, no. 1 (2005): 21-5, doi:10.1080/08998280.2005.11928028.

2. Lady Mary Wortley Montague brought the technique of immunization from Istanbul to the Western world.

3. Richard Fisher, Edward Jenner 1749-1823 (St. Edmunds: St Edmundsbury Press, 1991), 14, as cited in Blake Edward De Leon, “The Perception of Medical

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Ethics within the Case Study and Campaign of Jennerian Vaccination, Harvard University thesis, November 2018, 8-9, https://dash.harvard.edu/bitstream/ handle/1/37945151/DELEON-DOCUMENT-2018. pdf?sequence=1&isAllowed=y.

4. De Leon, 42-48.

5. A note on the word vaccine: Originally, the technique was termed “variolation,” and it meant to be infected with a weakened form of the original disease. Vaccination is a term created by Jenner that refers to the Latin noun “vacca,” or cow. So in his use of the term, he acknowledges his injection was derived from cows.

6. José Esparza et al., “Early Smallpox Vaccine Manufacturing in the United States: Introduction of the “Animal Vaccine” in 1870, Establishment of “Vaccine Farms”, and the Beginnings of the Vaccine Industry.” Vaccine 38, no.

30 (2020): 4773-79, doi:10.1016/j.vaccine.2020.05.037.

7. Edward A. Belongia and Allison L. Naleway, “Smallpox Vaccine: The Good, the Bad, and the Ugly,” Clinical Medicine & Research 1, no. 2 (2003): 87-92, doi:10.3121/ cmr.1.2.87.

8. Cary P. Gross and Kent A. Sepkowitz, “The Myth of the Medical Breakthrough: Smallpox, Vaccination, and Jenner Reconsidered,” International Journal of Infectious Diseases 3, no. 1 (1998): 54-60, doi:10.1016/ s1201-9712(98)90096-0.

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T H I N K I N G G L O B A L LY

THE GUIDING PRINCIPLES

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e are living in a time requiring deep humility. How is it that our world, despite all of its resources, technological and diagnostic advances, cannot work together more efficiently to get the upper hand on a virus?

The pandemic ushered in a global shared reality — a reality where we more deeply understand our interconnectedness.

And with this shared experience, we have the chance to evolve, or reconstruct partnerships and practices to meet the new realiBRUCE ties. It will take humility to see COMPTON that what was before might not have been what was best.

This column is the second of a series in which CHA members and global partners highlight one of the six Guiding Principles for Conducting International Health Activities in the context of their

own global efforts. The series is a call for all our ministry’s efforts to be more sensitive to the realities and stated needs on the ground in low- and middle-income communities rather than pursuing our goals for what we hope to provide.

Sharing her experiences with the Guiding Principle of Humility is Camille Grippon, who serves as the system director of Global Ministries at Bon Secours Mercy Health. I have long respected her thoughtful approach to international health activities. I hope her message resonates and allows anyone who participates in or plans global health exercises to look at their own approaches from a different perspective.

Humility CAMILLE GRIPPON

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or those who work in Global Health, there are often stories shared of two distinct realities. One reality centers on those who value and cultivate right relationships with local partners and another reality centers on those who seek their own or their organization’s interest.

This was true before COVID-19, and it will likely be true post-pandemic. However, Humility, one of the Guiding Principles for Conducting International Health Activities, can teach people and organizations a lot about cooperation and collaboration in a time that we need it the most.

Before COVID-19, many groups conducting international trips did not involve local leadership.

I remember hearing about an outreach trip over a decade ago where a large U.S. group arrived to a country with no host present. When asked why there was no host present, the response was that the flight tickets had already been purchased before an arrangement with the host had been finalized, and time was money. Host or no host, the trip

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was not rescheduled and, needless to say, it was not successful.

If there hasn’t been enough planning in partnership with those in-country, actions shouldn’t continue for a visit simply because tickets have already been purchased. Just because we can, does not mean we should. Many well-intentioned individuals volunteer their time and skill in communities that are vulnerable throughout the world. Their intentions are noble, yet their actions sometimes lack appropriate self-reflection and self-awareness to ensure that they are entering the country as guests, practicing humility and building right relationships based on mutuality.

Relationships marked by mutuality build relationships where both domestic and international partners benefit and take away relevant lessons.

PRACTICING HUMILITY

A foundational example of humility in my mind is the image of Jesus washing the feet of his disci-

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ples. Even though there are many interpretations preconceived notions. It is vital for international of why Jesus washed his disciples’ feet, in part he health care guests, whether they come as a single was humbling himself in service to others, and in practitioner or an entire non-governmental ordoing so, Jesus set an example for others to follow. ganization, to listen actively and understand that So much of our work in Catholic health care everyone has something to learn.

Countless local partners can draw from the example complain of international of Jesus, especially in intervisitors being overbearing, national settings. Leaders opinionated and even arrocan practice humility to set gant upon arrival. Usually, the tone for how their teams this occurs when guests try should conduct themselves. to “size up” the country, the Sometimes people shy away problem and the people too from the word humility, esquickly and begin to voice pecially to define a leader, opinions that are loosely because humility is somebased on fact or common times understood as a feelcultural norms. Prior to ing of low self-worth or lack We all have something to learn forming an opinion, guests of pride, but humility is far Partnerships marked by mutuality should enter the country from that. Humility is to be and respect build relationships with a willingness to learn, present toward others more where both the U.S. and listen and slowly form a rethan to yourself and become international partners benefit and lationship based on mutual less self-absorbed in order to take away relevant lessons. True trust. truly serve others. cultural competence is necessary One example of practicfor a two-way learning process in ing humility in a leadership STICK TO THE STANDARDS, role took place in 2014 during ALWAYS! any development activity. an in-country assessment.

In the last few decades, During one of the pre-trip international trips have phone calls, the president of a much-respected increased sharply as has the literature on best organization told me that as the lead primary sur- practices. International trips can be successful geon he was the leader of the mission. He added if standards are followed. As an example, in 2015 if he needed to clean the floors at the hospital that CHA published Guiding Principles for Conducthe would do it and expect all the members of his ing International Health Activities to help Cathoteam to do the same. lic health care organizations most appropriately While this proposition seemed unusual, it set conduct international work. Humility is listed as the tone for others. Neither he nor anyone else one of the six principles. The section on Humility was expected to be superior to anyone. All were details the importance of mutuality and right reexpected to serve the needs that may have arisen, lationships, while also explaining the importance whether those were clinical or non-clinical needs. of cultural competence.

I believe this was his attempt to counter some of Bon Secours Mercy Health applies best practhe attitudes of superiority that come with inter- tices including the Guiding Principles and other national trips. For the surgeon, practicing humil- guidance from CHA publications during all preity was a behavioral compass that ensured every- trip formation led by the Global Ministries ofone would strip themselves of their own ego and fice. All international participants take part in a bring their best self to the service of others.

12-hour pre-trip session focused on topics such as our Catholic foundation, the clinical and cultural reality, ethical scenarios, safety discussions, LISTEN AND LEARN Many shortcomings in international health care country profile presentations, data collection could be avoided by a simple pre-requisite of hu- discussions, patient pre-screening studies and asmility, which includes active listening without sessments, and cultural awareness dialogue. Most

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importantly, the local host is involved in the training sessions to begin to build a relationship prior to arriving in-country.

Our formation opening prayer is from Saint Martín de Porres, a Peruvian saint known primarily for his humility. We read the prayer as a group and reflect on part of the passage “mindful of your unbounded and helpful charity to all levels of society and also of your meekness and humility of heart, we offer our petitions to you.”

Upon completion of the training, the session that is most highly rated is the exchange with the local host. One participant mentioned how important it is to have a dedicated space to tune out our own narrative in order to learn about the communities we serve.

HUMILITY IN CATHOLIC HEALTH CARE

When we are able to eliminate or reduce the harm of COVID-19, traveling abroad likely will resume.

At that juncture, we will need to know what lessons we learned from the COVID-19 pandemic.

Did our inability to fly into a country change how we can work with others internationally going forward? Can technology take the place of some outreach trips or fly-in activities? How can we build solutions locally? Are we committed to long-term solutions, local empowerment

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and sustainability? Reflecting on some of those questions will help individuals and organizations strengthen their international interactions and partnerships. It will also help to assess opportunities for improvement.

Catholic health care is charged with a great responsibility to practice humility. As part of our Catholic identity, we must ensure that our actions are consistent with who we say we are. Can we truly express dignity, solidarity and a preferential option for the poor without practicing humility? It might be possible, but it would not be correct. Similar to flying into another country without making sure the host could be present, we must remember that just because we can does not mean we should.

Catholic health care is called to make a difference in every encounter. In international settings, communities are especially vulnerable and deserve the most genuine expression of humility, which lacks all forms of selfishness and empty conceit.

Humility is one of the best attributes we can always bring to international Catholic health care, a true attempt to express the example of Jesus.

CAMILLE GRIPPON is the system director, global ministries for Bon Secours Mercy Health. She is based in Marriottsville, Maryland.

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A G E F R I E N D LY

AGING WELL AT HOME THROUGH THE CAPABLE PROGRAM ALICE F. BONNER, PHD, RN, FAAN and SARAH L. SZANTON, PHD, ANP, FAAN

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magine that after sustaining a few falls without serious injuries in the past year, one evening you slip on some ice on the pavement and break your right hip. After surgery and a short period in a rehabilitation and skilled nursing facility, the clinical team tells you that you are not safe to go home alone. Despite this recommendation, you are determined to return to your apartment and your pet cat.

After a psychiatric evaluation determines that tion steps to take before the next visit.

During the 2020 COVID-19 pandemic, a numyou have capacity to make this decision, you are ready to return home. As part of the discharge ber of CAPABLE programs were on “pause” for a process, the discharge planner makes a referral to few months due to older adults not wanting health care professionals or others visiting inside their the CAPABLE program.

CAPABLE combines the skills and resources homes. Some programs continued with existing of an occupational therapist, a registered nurse clients, following state and federal guidelines for and a handyperson or similar worker to sup- the use of masks, hand hygiene and personal proport older adults to age in the place that they call tective equipment (PPE) as indicated. Now, most home. Developed by Sarah Szanton, PhD, Laura CAPABLE programs are back to their usual schedGitlin, PhD, and colleagues at the Johns Hopkins ules and routines.

School of Nursing about 10 years ago, the program is built on the principles CAPABLE combines the skills and that older adults often have capacity resources of an occupational to improve functional status (ability to bathe, dress, use the toilet, transfer therapist, a registered nurse and a from a chair or walk by themselves) — but they may not recognize how handyperson or similar worker to to adapt basic approaches or resolve support older adults to age in the symptoms to engage in those activities more independently. place that they call home.

CAPABLE promotes autonomy and independence, using motivaThe occupational therapist may focus on protional interviewing and open-ended questions to build rapport with older adults from the first en- moting mobility, identifying needs for common counter. (Motivational interviewing is a specific household items such as a sturdy step stool or method of communication to empower a person banister for stairs, and building the participant’s toward making decisions and reaching their own self-confidence. The registered nurse spends time goals.) Health care settings can sometimes feel on pain management, depressive symptoms, exerrushed and impersonal, especially for older adults cise for strengthening lower extremities and core with impaired hearing and/or vision. By coming muscles. The nurse reviews the person’s mediinto someone’s home, the nurse and occupational cation regimen, looking for particular high-risk therapist learn about environmental challenges medications or multiple medications that may that the participant faces each day. After thorough have interactions and side effects.

Based on the participant’s goals, the occupaassessments, the nurse and occupational therapist are able to target areas of concern raised by the tional therapist and the person develop a work participant and can coach her or him through ac- order for the handyworker that includes simple

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home repair and modification as well as useful Therefore, it is considered a preventive model, rehousehold items such as LED light bulbs or grab lying on and building the strengths and skills of bars in the shower. The occupational therapist older adults.

We strongly encourage close collaboration reviews that work order with the participant and handyperson and ensures that the participant is between the participant, CAPABLE team and the clear on the home modification to be done. There is a CAPABLE training While the primary mission of manual for the nurse and occupational therapist, and a guideline for CAPABLE is to support older adults in the handyperson that they share with the place they call home and where each other.

they would like to age independently, there are significant cost savings to the health system, taxpayers and government programs.

WHY DOES IT WORK?

People often ask why CAPABLE has been so successful. Data from multiple research studies demonstrate improved activities of daily living, better depression scores, and lower acute care costs such as hospitalizations and emergency department visits.1, 2 While functional status (being able to move around independently or with adaptive equipment) is sometimes discussed during medical or hospital visits, it often is not specifically addressed until after an event, such as a fall or medication interaction.

CAPABLE may intervene earlier in the process, before serious events or accidents have occurred, and works to build self-confidence and strengthen the person’s skills in order to avoid consequences.

FINDING SOLUTIONS

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n her second visit with one CAPABLE program participant, an occupational therapist noticed the participant seemed rather depressed. The man explained that the one thing he used to love doing was mowing his own lawn. Because his outdoor shed was falling apart, it was no longer safe for him to retrieve his lawn mower, so he hadn’t been able to mow his lawn in years. The occupational therapist conferred with the registered nurse, and the occupational therapist wrote a work order for a laborer to fix the floor of the shed.

A few months later, the man couldn’t believe his eyes. The shed was rebuilt safely, and he was able to take out the lawn mower and mow his own lawn again. That put a real smile on his face.

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participant’s primary care provider/team. We believe this is another strength of the CAPABLE model — integration and interdisciplinary coordination with the primary care team.

The CAPABLE program takes place over about four to five months. During that time, typically the occupational therapist makes six visits, the nurse makes four visits and the handyworker spends a day or so in the home. While health professionals see themselves as coaches or mentors, the older adult sets his/her own goals, works to develop the care plan and practices activities between each visit.

CAPABLE is now being implemented in over 33 sites in 17 states. CAPABLE is funded through a variety of financial supports, including local philanthropy or foundations, state and/or federal grants, housing grants and other vehicles. Medicare Advantage plans may add CAPABLE (goal attainment) language to their suite of services under the Chronic Care Act or other recent legislative or regulatory updates. While traditional fee-for-service Medicare does not cover the cost of the CAPABLE program yet, the Physician Payment Technical Advisory Committee (PPTAC) unanimously recommended that Medicare consider covering CAPABLE during the annual wellness visit or similar encounter.

COST IMPLICATIONS

While the primary mission of CAPABLE is to support older adults in the place they call home

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and where they would like to age independently, there are significant cost savings to the health system, taxpayers and government programs. In a Health Affairs paper describing several research studies, Dr. Sarah Ruiz and colleagues reported that CAPABLE saved Medicare about $22,000 per participant over two years.3 In a 2017 paper in the Journal of the American Geriatrics Society, Szanton and colleagues reported that CAPABLE also saved Medicaid about $10,000 per participant per year.4 Thus, the total savings to both state and federal government programs far exceeds the annual costs of the program (by about 3-7 times CAPABLE’s cost).

For more information about CAPABLE, please contact us at: CAPABLEinfo@jhu.edu, or email Alice Bonner at abonner9@jh.edu.

CONCLUSION

NOTES 1. Sarah Ruiz et al., “Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use,” Health Affairs 36, no. 3 (2017): 425-32, doi: 10.1377/hlthaff.2016.1305.

2. Sarah L. Szanton et al., “Medicaid Cost Savings of a Preventive Home Visit Program for Disabled Older Adults,” Journal of the American Geriatrics Society (2017): 1-7, doi: 10.1111/jgs.15143.

3. Ruiz et al., “Innovative Home Visit.”

4. Szanton et al., “Medicaid Cost Savings.”

Given the national shift to value-based purchasing, newer alternative payment models and accountable care organizations within health systems, the time seems right for exploring CAPABLE as a Home and Community Based Services model designed to promote healthy, positive aging in community. If we can deliver programs and services that enable older adults to design and manage their own goals and care plans, and extend their tenure in community, results such as better quality of life, enhanced well-being and mobility, and enabling older people to contribute to their communities are likely outcomes.

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ALICE BONNER is currently adjunct faculty and director of strategic partnerships for the CAPABLE Program at the Johns Hopkins University School of Nursing and senior advisor for aging at the Institute for Healthcare Improvement. SARAH L. SZANTON is the Health Equity and Social Justice Endowed Professor and director of the Center for Innovative Care in Aging at the Johns Hopkins Schools of Nursing and Public Health.

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P R AY E R

SERVICE

To Be a Fellow-Worker with God CARRIE MEYER MCGRATH, MDIV, MAS DIRECTOR, MISSION SERVICES, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

CALL TO PRAYER Leader: God calls each of us to a specific work, to give of ourselves in the service of others and our community. This year marks the 200th anniversary of Florence Nightingale’s birth. A pioneer of modern nursing, Nightingale felt called away from her life of elite privilege to serve as a nurse. Against the desires of her parents that she marry well and raise a family, Nightingale spent her life caring for the sick in cities and on battlefields. She worked to elevate the nursing profession, bringing rigor, discipline and respectability to the role. She viewed her calling as a partnership with God, who holds all things together.

Reader: “Unless I am, a fellow-worker with Divine Power, who is working up all our poor little puny efforts into a whole — a whole of which our efforts are only parts, and worth anything only in as much as they are parts — shall I work at all? To be a fellow-worker with God is the highest inspiration of which we can conceive humanity capable.”

— Note of Interrogation, Florence Nightingale

Leader: In a year when nurses and health care professionals are giving more of themselves than ever before, we must step back and consider our efforts as a part of God’s plan. Each time we offer our best, serve with compassion, seek justice, and love without fear, we give ourselves to the mighty work of Divine Providence. As we

hold and support others, we also let ourselves be held and supported in the love and greatness of God. Reader: A reading from the prophet Ezekiel (Ezekiel 34: 15-16, 25-26, 31) I myself will be the shepherd of my sheep, and I will make them lie down, says the Lord God. I will seek the lost, and I will bring back the strayed, and I will bind up the injured, and I will strengthen the weak, but the fat and the strong I will destroy. I will feed them with justice. I will make with them a covenant of peace and banish wild animals from the land, so that they may live in the wild and sleep in the woods securely. I will make them and the region around my hill a blessing; and I will send down the showers in their season; they shall be showers of blessing. You are my sheep, the sheep of my pasture and I am your God, says the Lord God. Leader: Loving God, Good Shepherd, we thank you for the nurses in our midst and for all those who serve the sick. Sustain them and all of us, keeping your people healthy in mind and body.

Give us the strength to serve with compassion and the humility to be led and comforted by you. Give us the grace to be present to others and the vulnerability to share our own needs.

We pray that you will take our offerings in this time and use them for your glory and goodness.

Amen.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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