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TEXASNURSING M A G A Z I N E COVID -19
FOREVER CHANGED
Reluctant Heroes, life-saving experts, caring providers Looking Beyond the Crisis— Preparing now for after COVID-19
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | I s s u e 2 , 2 0 2 0
ISSUE 2, 2020 Volume 94, Number 2 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
VISION Nurses transforming health TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas. One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044 Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2020 © Texas Nurses Association
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BOARD OF DIRECTORS OFFICERS: Jeff Watson, DNP, RN, NEA-BC, President Jeff.Watson@ttuhsc.edu Tamara “Tammy” Eades, DNP, MSN, RN, President-Elect eades@uta.edu Amy McCarthy, MSN, RNC-MNN, NE-BC, Secretary amykoshy@gmail.com Gayle Dasher, PhD, RN, ANP-BC, Treasurer gayle.dasher@christushealth.org DIRECTORS: Melinda Hester, DNP, RN-BC melhester@austin.rr.com Donna Wallis, MBA, MSN, RN DRWALLIS@baptisthealthsystem.com Patricia Freier, MSN, RN-BC, CPHQ pfreier@covhs.org Ernestine “Tina” Cuellar, PhD, RN, PMHCNS-BC tinaatutmb@aol.com EXECUTIVE DIRECTOR: Cindy Zolnierek, PhD, RN, CAE
TNA DISTRICT AND PRESIDENT Dist.1:
Clarissa Silva, PhD, MSN, BSN, RN clarissa.silva@ttuhsc.edu
Dist. 3:
Margie Dorman-O’Donnell, MSN, RN margiedo@sbcglobal.net; District office: Jamie R. Rivera, JamieRivera@texashealth.org
Dist. 4:
Natalie D. Garry, MSN, APRN, GNP-BC Ngarry1617@gmail.com, tnad4.nursingnetwork.com
Dist. 5:
Leah Koen May, MSN, RN, NE-BC President.TNAd5@gmail.com, tna5.org
Dist. 7:
Stacy Cooper, MSN, RN staycoop@yahoo.com, tnadistrict7@gmail.com
Dist. 8:
Patricia E. Alvoet, EdD, MSN, RN-BC pe.alvoet@gmail.com
Dist. 9:
Juliana Brixey, PhD, MPH, MSN, RN jjbrixey@hotmail.com; District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com
Dist. 17: Mari Cuellar, NEA-BC, MSN, RN mgrace2329@yahoo.com Dist. 18: Janice L. Miller, MSN, RN, ACM janice.miller@umchealthsystem.com Dist. 19: Anita Lowe, MSN, RN alowe@uttyler.edu Dist. 35: Chrystal G. Brown, MSN, RN cbrown@ntcc.edu At-Large: Contact TNA, 800-862-2022, ext. 129 brichey@texasnurses.org
CORRECTION: The print edition incorrectly ordered the authors of Preparing Now for After COVID-19 (p. 16). The digital edition is correct.
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Ethically Protecting Yourself and Patients Making Hard Decisions in a Crisis
14
PREPARING NOW
FOR AFTER COVID-19 The Need to Strengthen Public Health Nursing
YEAR OF THE
16
NURSE
PRACTICING REMOTELY
UNEXPECTED
Déjà Vu18
20
How COVID-19 parallels HIV
Contents IN EVERY ISSUE
FEATURES
5
8
10
13
22
PRESIDENT’S NOTES
NURSES ARE HEROES
REGULATORY COOPERATION
THE BACKBONE OF LONG-TERM CARE
MAKING ADVOCACY HAPPEN
TNA's 2020 Presidential SBAR
Even Though They Shouldn't Have to Be
Working with the Board of Nursing
Working with Certified Nursing Assistants During COVID-19
The Role of the Association in Representing Nurses in
6
Statewide Collaborations
TNA MEMBER NEWS Kudos, TNA News, Member Get a Member
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How important is the Prescription Monitoring Program? Vital As of March 1, 2020, all Texas prescribers are required by state law to check the Prescription Monitoring Program before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol. Every patient. Every time.
Sign on before you sign off.
President’s Notes Jeff Watson, DNP, RN, NEA-BC Tammy Eades, DNP, RN
TNA'S 2020 PRESIDENTIAL SBAR Handing Off Board Leadership in Unprecedented Times
AT THE CLOSE OF 2019, nurses across the world were preparing for 2020, the Year of the Nurse and Midwife. As we rang in the New Year, I am not sure that any among us would have imagined that our profession would be thrust into the headlines as the result of a worldwide pandemic. The COVID-19 health crisis, and the associated heartwrenching stories, has sent media outlets searching for nurses and sharing their experiences in real time. This documentation of nursing is building new awareness of nurses, demonstrated by people stopping at 7 p.m. each day to applaud and extend gratitude for health care workers as one shift ends and another shift begins. There is comfort in knowing when one nurse leaves, another shows up to continue the work. We all know that the work of our profession is unending. Likewise, as the work of the Texas Nurses Association continues, shifts change. My report: SITUATION: I write to inform you of the upcoming planned transition in TNA leadership, which will occur on July 1, 2020. BACKGROUND: In February 2019, TNA membership elected Dr. Tammy Eades to the office of President-Elect. Eades received a Bachelor of Science in Nursing from Texas Tech University, a Master of Science in Nursing from West Texas A&M, and a Doctorate of Nursing Practice from Texas Christian University. ASSESSMENT: Eades spent the past year building on her existing governance acumen to ready herself to lead the association. She firmly established herself as a leader within the American Nurses Association and took every opportunity to represent TNA, establishing herself among peer organizations. RECOMMENDATION: Eades steps into this role at a very uncertain time. I am convinced that the right leader always emerges for the right time. And her time is now. Please join me in a rousing welcome for our new TNA President, Dr. Tammy Eades! Peace, Jeff
Thank you, Dr. Watson, for that warm welcome. I am honored to be a part of the Texas Nurses Association and I hope everyone is staying healthy, strong, and positive during the COVID-19 pandemic. This year has presented some challenging times for us. I thank and honor my fellow nurses who are on the frontlines taking care of us, our patients, and our families.
I am proud of our nurses and how they have become representatives for nursing during the COVID-19 pandemic, on social media, in the news media, and in collaborative health care committees. Increasing our membership will make our nursing voice stronger and empower us to advance the profession. You are the real heroes! TNA’s membership reminds me of our Texas highways during the spring, when they are lined with bluebonnets, Indian paintbrushes, and buttercups. Each year they spread out more and more, painting our roadsides to become a magnificent view. TNA’s mission “Empowering Texas Nurses to Advance the Profession” is like our field of flowers. We grow stronger and more beautiful together. I am proud of our nurses and how they have become representatives for nursing and health care during the COVID-19 pandemic, on social media, in the news media, and in collaborative health care committees. Increasing our membership will make our nursing voice stronger and empower us to advance the profession. I truly believe we will come out of this pandemic stronger, more beautiful, and powerful. I am proud to stand beside you and call myself a nurse. I look forward to being your new TNA president and working with you for the betterment of our association. Thank you for all you do, Tammy i
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS Cindy Zolnierek, PhD, RN, CAE, was awarded the 2020 American Nurses Association (ANA) Advocacy Award, which recognizes a nurse who embraces the role of advocate; is collaborative, committed, compassionate, and knowledgeable; and has contributed through political, professional, or social advocacy. Zolnierek is the Chief Executive Officer of the Texas Nurses Association (TNA). Jeanie L. Sauerland, MA, BSN, RN, was awarded the 2020 ANA Leadership in Ethics Award, which recognizes a nurse who has demonstrated the highest standards of ethics and leadership in daily nursing practice. Sauerland is assistant director of the Nursing Ethics Service at the University Health System, where she provides ethics consultation, reviews and develops policy, and supports clinical staff with ethical issues and moral distress. Viola Hebert, RN, was one of 85 delegates sworn in for a two-year term with the 18th Texas Silver-Haired Legislature. Hebert has a background in nursing, healthcare IT, consulting, sales, education, and training across military, public, and private sectors. She will serve on two committees during her term: the Elections and Credentials Committee and the Health and Human Resources Committee.
Mike Bennett, MSN, NE-BC, has been named chief nursing officer at the Menninger Clinic. A 34-year employee of Menninger, Bennett has been interim chief nursing officer since September 2018. He recently led the implementation of an innovative electronic health record system and the development of a new service through Menninger’s Compass Program, an inpatient treatment program for young adults.
TNA NEWS Please welcome Serena Bumpus, DNP, RN, NEA-BC, and Jason Hassay, JD, to the TNA team. Serena R. Bumpus, DNP, RN, NEA-BC, assumed the position of director of practice in early March and immediately stepped up during the COVID-19 pandemic by creating resources and serving as the voice for nurses in print, radio, and TV press outlets. Bumpus most recently served as regional director of nursing for the Austin–Round Rock region of Baylor Scott and White Health. Jason Hassay, JD, is the new general counsel and director of government affairs for TNA, and directs all legal affairs, policy development, and political engagement for the association, as well as all lobbying and PAC activity at the Texas
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Capitol. Hassay previously worked at the Texas Association of Counties and spent over ten years working for three Texas senators, as general counsel and chief of staff.
MEMBER GET A MEMBER Thank you to all the members who participated in the Member Get a Member Campaign that ran from Nov. 1, 2019, to April 30, 2020. We had 82 recruiters, and TNA membership has grown by 637! In addition to our monthly winners, every member who recruited at least one new member was entered into a drawing for additional prizes. Congratulations to: Our monthly $25 Amazon gift card winners: Christy Armenta, Edtrina Moss, Chinyere Turner, Inestral Pierre, Angela Kruse, and Roxanna Bonilla
Third place (free download of Introduction to Texas Nursing): Simbarashe "Portia" Tirimboyi, Inestral Pierre, Claudia Sebastian, Felicia Hicks, and Raul Correa.
Second place ($150 Reebok gift card): Darla Smith, Kari Farese, and Francoise Le.
First Place (Massage Envy Gift Card plus Texas Hill Country Lavender spa products): Cindy Andrews and Karen Jeffries.
Grand Prize winner ($500 Visa Gift Card*): Emily Martinez.
*The gift card is being substituted for the original Grand Prize of registration and housing for the 2020 TNA Policy Summit which has been cancelled. i
Members can send news to editor@texasnurses.org.
SAVE THE DATE!
2021 NURSE DAY AT THE CAPITOL Monday, February 22, 2021 Sheraton Austin Join TNA to talk with legislators! Influence the policy that shapes nurse practice, impacts nurses’ workplaces, and creates an environment where nurses can provide the best care to Texans. Get all the tools you need to successfully communicate with lawmakers.
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Even though they shouldn't have to be. A NOTE FROM THE CEO Cindy Zolnierek, PhD, RN, CAE Chief Executive Officer of TNA
THE WORLD HEALTH ORGANIZATION designated 2020 as the International Year of the Nurse and Midwife to highlight the critical role of nurses in improving health, achieving gender equality, and supporting economic growth, with particular emphasis on the role nurses play in guiding policy. Little did we know that as we ushered in the Year of the Nurse, the COVID-19 pandemic would appear and change everything. As the largest group of health care professionals, present wherever health care is provided, nurses have an essential role in crisis response—every person requiring care for COVID-19 will encounter a nurse. Yet nurses are often overlooked, and are asked every day to perform at a high level, even as practices, rules, and regulations change. From license renewals to mandatory overtime to personal protective equipment (PPE) practices, nurses were expected to keep up with countless changes while also learning about the clinical pathology and treatment for a novel disease. Nurses are well versed in infection prevention and control practices, yet, during the COVID-19 crisis, these well-established practices changed. In response to shortages of PPE, the Centers for Disease Control and Prevention issued recommendations to preserve and extend the use of supplies, such as
As this crisis continues, we want Texas nurses to know that we hear you. reusing and decontaminating masks. Nurses were alarmed. Is this practice safe? Am I safe? Will I acquire the virus? Will I transmit it to my patients? My family? Across the nation, nurses felt they weren’t valued. And they felt they were being asked to risk their lives just to do their job. We listened, and we took your fears and concerns to heart. While working within CDC recommendations, TNA executed several advocacy efforts:
Collaborating with ANA’s Call to Action requesting action to obtain and distribute PPE supplies
Creating an Action Alert for Texas nurses to contact state legislators and urge their action in gaining PPE for Texas
Participating with partner associations, regulatory agencies, state agencies, and the governor’s office to advocate for nurses
Providing webinars, Q&A sessions and web resources to inform nurses about their legal rights and advocacy protections in our current environment
As this crisis continues, we want Texas nurses to know that we hear you. We
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read every comment online. We respond to every phone call we can. We track and organize emails and survey responses. We listen to every nurse who shares their experience, from direct care providers to nurse leaders to educators. From PPE to furloughs to ethical concerns to workplace safety—we are listening and responding as quickly as we can. Meanwhile, on the frontlines, nursing innovation is at its best. When PPE was in short supply, nurses extended tubing length to enable IV pump placement outside patient rooms to reduce exposure. When clinics needed to a remote way to continue patient monitoring, nurses implemented telehealth technology. When constant use of PPE lead to indents on noses and bruising on ears, nurses developed accessories to make masks more comfortable. And to protect themselves and their patients, nurses have worked with biomedical labs to produce PPE using 3D printing, air conditioning filters, and other available materials. Nurses will get the job done. And TNA is working to ensure you have the support, resources, and protections to do just that. i
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REGULATORY COOPERATION Working with the Board of Nursing to Quickly Respond in a Crisis
TNA's relationship with the BON emphasizes a crucial component of successful nursing practice—mutual support among the entire nursing community. TO SLOW THE SPREAD of COVID-19 in the state, our elected leaders have made several decisions that directly affect nurses. Throughout this uncertain time, Texas Nurses Association (TNA) has been hard at work advocating for nurses, providing input on statewide task forces, and working closely with a number of organizations, including the Texas Board of Nursing (BON). Together, we’ve made sure nurses are safeguarded and have the information they need to work effectively. TNA and the BON have collaborated and partnered together for many years. This longstanding relationship helps protect Texas nurses while prioritizing a shared goal of patient safety. As the voice for nurses in Texas, TNA listens to nurse concerns and represents them at the state level, for instance, by sharing the need for PPE with state lawmakers. As a regulatory body, the BON primarily protects the welfare of Texans by ensuring licensed nurses practice safely. While we offer different perspectives, our strong working relationship helps TNA advocate for nurses. Since the state has prioritized the fight against COVID-19, TNA and the BON continue to collaborate to educate nurses. When nurses informed TNA about having to work without PPE, TNA worked with the BON to confirm our shared understanding of the nurse’s duty to the patient by reviewing their position statement. When Gover-
nor Greg Abbott announced several waivers related to nursing licensure and education, the BON worked with TNA to confirm details and provide guidance for nurses.
Since the state has prioritized the fight against COVID-19, TNA and the BON continue to collaborate to educate nurses. These waivers include: Temporarily suspending the national certification examination requirement for new APRN graduates to allow them to work under direct supervision without prescriptive authority;
Waived regulations allowing APRNs to reactivate inactive licenses;
Waived regulations allowing LVNs, RNS, and APRNs a 6-month grace period for licensure renewal;
Waived regulations that limited the APRN’s ability to issue prescriptions for controlled substances for chronic pain via telemedicine if the delegating physicians agree to permit them to issue these refills via telemedicine;
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Fast-tracking the temporary licensing of out-of-state nurses and other license types to assist in Texas’ response to COVID-19;
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Allowing nurses with inactive licenses or retired licenses to reactivate their licenses;
Allowing temporary permit extensions to practice for graduate nurses and graduate vocational nurses who have yet to take their licensure exam; and
Allowing nursing students in their final year of nursing school to meet their clinical objectives by exceeding the 50% limit on simulated experiences.
Additionally, TNA, the Texas Organization of Nurse Leaders, and the BON issued a joint statement in March acknowledging challenges in the current work environment and thanking nurses for their steadfast dedication to the profession. Constantly changing protocols and policies create fear, anxiety, and frustration as nurses struggle to understand the rationale and scientific evidence behind unfamiliar practices. Consistent and clear vertical and horizontal communication plays a crucial role in supporting nurses as they do their jobs during this crisis. Our relationship with the BON also highlights a crucial component of successful nursing practice: mutual support among the entire nursing community. Nurses work best when they support each other. And advocacy is best served when there are many voices aligned with one consistent message. Our goal will always be to continue to carry the voice of nursing forward. i
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THE BACKBONE OF LONG-TERM CARE
Working with Certified Nursing Assistants During COVID-19 By Shanna Howard
CERTIFIED NURSING ASSISTANTS (CNAs), sometimes called nurse aides, assist with the direct care of people under the supervision of a registered nurse (RN) or licensed vocational nurse (LVN). In a long-term care (LTC) facility, CNAs help residents bathe, dress, brush their teeth, use the toilet, eat meals, and other activities of daily living, while also obtaining vital signs and making observations. Due to this close and regular interaction, CNAs come to know LTC residents well and build close relationships with them.
The resident primarily spoke Spanish, so Spanish-speaking CNA Audrey Cadena quickly stepped up to join the residents in isolation. Cadena and Director of Staff Development Jackie Shocklely, BSN, RN, focused on making the residents comfortable and safe, ensuring necessary supplies were available within the isolation unit and implementing standards to conserve personal protective equipment through extended wear and reuse. That night, two additional residents developed symptoms and joined the unit.
“They are the backbone of long-term care,” says Kevin Gluch, RN, Director of Nursing at Westminster in Austin. “They are with the residents 24/7, assisting them with the most intimate levels of care. They are in a position to notice changes in the resident and bring those to the nurse’s attention.”
“Our two turned to four quickly, and Audrey never batted an eye,” says Shockley. “She went to work making everybody comfortable and getting them settled in for the night.” Thankfully, the tests were negative, but the value CNAs like Cadena provide in LTC is even more evident during a potential outbreak.
MEETING THE CHALLENGE
CARING IN A CRISIS
The COVID-19 outbreak introduced special challenges for residential care settings, like LTC, where residents may have compromising health conditions and infectious disease can spread quickly if not well managed. At the Legacy at Town Creek in Palestine, staff had to rapidly respond when a resident began to show symptoms of COVID-19. She exhibited a fever, sore throat, and headache. Following negative flu and strep tests and a chest X-ray showing prominent bronchial changes, a COVID-19 test was ordered and staff prepared to move the resident and her roommate into a recently established isolation unit.
Across the nation, LTC facilities are implementing prevention methods for COVID-19, like wearing additional PPE. Unfortunately, safety precautions limit interaction. “Just by wearing masks, you affect a resident’s ability to see the nurse’s or CNA’s smiles and emotions,” says Gluch. Prevention has also required social distancing within the facility and limiting access to the facility. “Families can’t come either. And you can’t stand and have a conversation if you’re six feet apart. It’s changed how you have those conversations.” Like hospital staff, LTC staff face con-
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cerns that going to work may mean becoming ill themselves or transmitting the virus to their families. While there is a good deal of attention on the risks nurses face in our current environment, the role of CNAs is less appreciated. Gluch and Shockley have witnessed their dedication to patients. “With so much emotion and uncertainty surrounding COVID-19,” says Shockley, “I think the many selfless acts of our CNAs in long-term care facilities are being overlooked. They are truly the ones providing hands-on, face-to-face direct care.” Shockley says that we need CNAs now more than ever. In Texas, the median CNA turnover rate was 67.4% in 2019.1 Shockley endorses a movement to fasttrack CNA training. “During these trying times, I believe our need today is as great as the need was in World War II when nurse aides proved to be priceless.” In fact, on March 30, 2020, the Centers for Medicare and Medicaid Services issued a waiver of certain requirements for the training and certification of nurse aides in nursing homes.2 No matter how the pandemic progress, Shockley says, “The giving hearts of these CNAs will not be forgotten.” i REFERENCES 1. Texas Center for Nursing Workforce Studies. (2019). Long Term Care Nurse Staffing Study, Highlights and Recommendations. Texas Department of State Health Services. 2. Centers for Medicare and Medicaid Studies. (2020). COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. Department of Health and Human Services.
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Ethically Protecting Yourself and Patients How Nurses Make Hard Decisions During a Health Crisis By Jeanie L. Sauerland, MA, BSN, RN
AT FIRST GLANCE, traditional patientfocused care models may seem to conflict with public-health focused care models. Changing focus from one to the other, even when the change appears ethically supportable, may lead to moral distress. Nurses may face a dilemma, particularly if there are scarce resources available and the standard of care cannot be provided to all those who might benefit. Health care leaders have an ethical obligation to develop policies and guidelines for use during a public health emergency. These duties include (1) a duty to plan and manage uncertainty; (2) a duty to safeguard and support workers and protect vulnerable populations; and (3) a duty to guide and develop contingency and crisis standards of care.1 COVID-19 presents a unique set of challenges to nurses and other health care workers. Nurses, on the front lines fighting for patients, are also among the highest risk group for contracting the disease, particularly if there are shortages of personal protective equipment (PPE).2 In this unique position, nurses need to protect themselves and the public through advocacy for the allocation of appropriate PPE and developing crisis standards of care.
CONFRONTING ETHICAL DILEMMAS
In the context of COVID-19, protecting oneself is protecting the patient and other community members. priorities without an obvious solution. COVID-19, at first glance, may appear to present such a dilemma. The American Nurses Association (ANA) Code of Ethics for Nurses contains two provisions that may initially appear in conflict.3 Provision Two states that the nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. Provision Five of the ANA Code of Ethics states that the nurse owes the same duties to self as to others, including the responsibility to promote health and safety. Some nurses may hesitate in providing care due to the risk to self, potentially placing the remaining nursing staff at greater risk.4 Other nurses may be highly motivated to provide care, despite the risks to self. Whether or not the nurse has a moral obligation to act in a crisis is dependent on if:
The patient is at significant risk of harm, loss, or damage if the nurse does not assist;
The intervention or care is directly related to preventing harm;
Care will probably prevent harm or loss; and
The benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse.5
In an ethical dilemma, nurses face a problem in deciding between two moral
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In the context of COVID-19, protecting oneself is protecting the patient and other community members. A nurse exposed to COVID-19 while caring for a patient risks not only harm to self, but also spreading the virus to vulnerable populations, including other patients and family members. Nurses must evaluate the risk-to-benefit ratio before engaging in care of COVID-19 patients. The duty to care remains in place and can be pursued safely if the nurses use the appropriate infection control measures, including the proper use of PPE.
TAKING LIFE-SAVING MEASURES In April, the American Heart Association published interim guidance for life support for COVID-19.2 “It is essential that providers protect themselves and their colleagues from unnecessary exposure. Exposed providers who contract COVID-19 further decrease the already strained workforce available to respond and have the potential to add additional strain if they become critically ill.” Strategies include donning appropriate PPE before entering the scene and limiting the number of personnel on the scene. Perhaps the most effective measures that nurses can take in protecting them-
selves and others from the dangers of COVID don’t take place in the work environment.
Hold leaders accountable to supply appropriate PPE and ensure staff members adhere to guidelines issued by the Centers for Disease Control and Prevention, the American Heart Association, etc.
Encourage family members and the public to abide by public health policies to control disease transmission such as hand-washing and social-distancing.
Advocate for early goals of care discussions regarding patient preferences during the COVID pandemic—particularly for people in high-risk populations.
Acknowledge the physical and emotional toll of caring for others during a pandemic and seek out opportunities for self-care.
Supporting one another and advocating for our needs will protect both nurses and the public who depend upon our care. While it is impossible to provide specific ethical guidance for every situation the nurse may encounter during the pandemic, nurses have the ability to draw upon their clinical training, critical thinking skills, and the support of peers and colleagues during this time. Supporting one another and advocating for our needs will protect both nurses and the public who depend upon our care. i
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REFERENCES 1. Berlinger, N., Wynia, M., Powell, T., et al. (2020). Novel Coronavirus SARS-CoV-2 (COVID-19) Guidelines for Institutional Ethics Services Respond to COVID-19. Managing Uncertainty, Safeguarding Communities, Guiding Practice. The Hastings Center.
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2. Edelson, Sasson, Chan, et al. (2020). Interim Guidance for Basic and Advanced Life Support for Life Support for Covid-19. American Heart Association. 3. American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements. 4. McNeill, C., Danita, A., Nash, T., Chilton, J., Swanson, M., (2020). Characterization of nurses’ duty to care and willingness to report. Nursing Ethics, 27(2), 348-359. 5. ANA Center for Ethics and Human Rights. (2015). Position Statement on Risk and Responsibility in Providing Nursing Care. American Nurses Association.
Call: 866-223-7675 Visit: Lamarnursing.com PAGE 15
I S S U E 2 , 2 0 2 0 | T E X A S N U R S I N G M AGA Z I N E
PREPARING NOW FOR AFTER COVID-19
The Need to Strengthen Public Health Nursing
By Monica J. Hughes, MSN, RN, NE-BC, CNE, and Lisa A. Campbell, DNP, RN, PHNA-BC UNTIL THE NOVEL CORONAVIRUS disease 2019 (COVID-19), most Texans were not aware that public health nurses (PHNs) and other public health professionals were hard at work promoting and protecting the health of our communities.
It is imperative that the growth and stabilization of the PHN workforce be addressed today for the benefit of the public’s health in the days to come.
The quiet work we engage in, largely unseen and taken for granted, means striving for equity in maternal health outcomes, educating youth on the risks of vaping, preventing childhood injury, tackling health disparities, and preparing for disasters. Society relies on public health’s presence and its success, without much thought on its structure, requirements, funding, or workforce.
outbreak. When the need for an urgent public health response arises—in this case, due to the COVID-19 pandemic—budgetary shortfalls and understaffing mean essential programmatic work is set aside.
That is, until a threat like COVID-19 emerges, and the emperor is revealed to be, at best, barely dressed. Every community, suburb, and big city across Texas now realizes the public health infrastructure is not adequate due to decades of chronic underfunding, job eliminations, and increased workload for health professionals.1
FALLING BEHIND THE CURVE In 2008, the Association of Public Health Nurses (formerly the Association for State and Territorial Directors of Nursing) made clear recommendations for a minimum ratio of one PHN to 5,000 residents, with even more nurses needed in vulnerable communities.2 The national PHN workforce falls almost 31,000 nurses short of that standard, and Texas is behind as well. Although no accurate accounting of PHNs in Texas exists, a 2020 study indicates that as a result of inadequate PHN staffing, PHN workloads continue to increase and the ability for public health to expand services in Texas is curtailed.3 The Texas Department of State Health Services has 154 local health entities spread across 11 regions and 254 Texas counties, providing essential public health services unrelated to an
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TAKING A BACKSEAT When outbreaks take priority, we are left with tuberculosis treatment programs understaffed, chronic disease surveillance unattended-to, connection to services for social programs limited, and public health clinics shuttered. PHNs typically managing these services are pulled away to meet more pressing challenges, resulting in broadening inequities for the most vulnerable who rely on the regular operation of public health services to help meet their needs. As a result of the current crisis, the federal government has set aside $1.5 billion to support public health departments as a part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act.4 This funding supports COVID-19-related activities, such as surveillance, disease testing and contact tracing, infection control, risk assessment and mitigation, and of course, increasing the availability of personal protective equipment. PHNs are educated, prepared, and ideally suited to assist, but reductions, combined with inconsistent recruitment, entry-level preparation, and inadequate training, have created a shortage in the state’s PHN workforce. The CARES Act funds, filtering down from the federal level to the state and then the local health entities, can and should be used to strengthen Texas’s PHN workforce.
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BUILDING A STRONGER WORKFORCE
Rewarding Careers
Public health nurses are all too familiar with the cycle that follows an outbreak of this kind: limited funding comes in, earmarked for a purpose related to the threat; in time, a renewed period of neglect settles in as interest in public health wanes again; a new disease (or disaster) emerges, and the cycle starts again. This virus has already revealed glaring inequities that affect health: food and housing insecurity, unemployment, and racially disparate outcomes.
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It doesn’t have to be this way. On the other side of this crisis, PHNs will go back to the quiet and unseen work they do, trying to put these things right. We invite you to join your voices with ours in advocacy, calling for a commitment to dedicate CARES Act funds to bolster the PHN workforce. It is imperative that the growth and stabilization of the PHN workforce be addressed today for the benefit of the public’s health in the days to come. Together, we must take a stand and call on our governmental entities to invest in a stronger foundation for our PHN future. i
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REFERENCES 1. Association of State and Territorial Directors of Nursing. (2008). Report on a Public Health Nurse to Population Ratio. Quad Council Coalition.
Contact:
2. Association of State and Territorial Health Departments. (2014). Budget cuts continue to affect the health of Americans.
Apply online: hhs.texas.gov/about-hhs/jobs-hhs
4. Coronavirus Aid, Relief, and Economic Security Act or the [CARES Act], H.R.748, 116th U.S. Cong., 2nd Sess. (2020).
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18D0738
Laura Hunter atof Aging Texas Department and Disability Services laura.hunter@hhsc.state.tx.us
3. The Texas Center for Nursing Workforce Studies. (2020). Texas governmental public health nurse staffing study. Texas Department of State Health Services.
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I S S U E 2 , 2 0 2 0 | T E X A S N U R S I N G M AGA Z I N E
UNEXPECTED
Déjà Vu How the COVID-19 Pandemic Parallels the 1980s HIV Crisis By Shanna Howard and Kanaka Sathasivan, MPH
FOR NURSES who have been practicing over the last four decades, the COVID-19 pandemic has been a stark parallel to the AIDS crisis of the late ‘80s, right down to seeing Dr. Anthony Fauci back on the news. From the zoonotic origins of the viruses, to the severe and rapid decline seen in people with AIDS or COVID-19, to how quickly both HIV and SARS-CoV-2 have spread with travel—nurses may be facing a new virus, but they are reliving the same challenges.
TRANSMISSION AND SPREAD The spread of both HIV and SARS-CoV-2 started with a lack of knowledge—especially upon their discovery—although communication, science, and technology move much faster now. While the novel coronavirus has been sequenced since January, more strains are found on a weekly basis but without clear connections to the severity of the illness. At the time of publication, we still do not know how many United States residents have gotten the virus and have inaccurate mortality and transmission rates. “You know HIV has really changed medicine,” says retired nurse educator Esther Wooten, BSN, MS. “You don’t sign an operative permit without being reminded about HIV. And if you get a transfusion, they’re exculpating themselves that it won’t be their fault if you catch HIV. It’s still out there, and that’s how prominent it became.”
Like HIV fueling homophobia, COVID-19 has fueled discrimination against AsianAmericans, nurses and doctors among them. Both diseases also have a serious impact on other minority communities. head nurse in the mid-80s at Bird S. Coler Memorial Hospital in New York City. She recalls being desperate for knowledge at the time. “I was wanting to learn, and I had all this literature that I got from the infectious disease faculty.” She read articles during her subway commute but remembers the fear people showed. “The subway was so jam-packed, and you would see slowly people start getting away from me.” While many illnesses start with confusion and anxiety, HIV and COVID-19 face a unique challenge that ultimately hinders public health: stigma.
STIGMA AND FEAR “Stigma is very big with HIV because of the transmission: bloodborne transmission with sexual activity or IV drug use,” says C. Andrew Martin, DNP, MS, RN, CNE, ACRN, CHPN, an HIV/AIDS certified registered nurse and doctorate of nursing practice program director and associate professor at Regis College.
Nurses today have information at their fingertips and the ease of communications means quick dissemination of knowledge. In contrast, the discovery of AIDS, and subsequently HIV, took several years.
That stigma led to people underestimating their own risk. “Everybody wanted to say it was just among homosexuals and that would be the only population affected,” says Wooten, “but all sexually active individuals were at risk.”
Maribel M. Marquez-Bhojani, MSHSA, BSN, RN, NPD-BC, was the
“COVID does not really have the stigma that HIV does, be-
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cause it’s not really driven by a specific activity other than social contact,” says Martin. “But now we’re beginning to see social contact as being a negative thing. We crave human connection, but now there’s a stigma attached to having human connection.”
“We need to be looking at it as a reflection of our public health system and how the United States deals with the social determinants of health,” says Martin. “Are we seeing a higher incidence of both diseases where there is poverty, unemployment, lack of insurance, food scarcity, and homelessness?”
In the ‘80s, nurses played a key role in caring for those with the illness, and just like now, sometimes nurses were the only human connection the patients had near the end of their lives. “Even affluent patients [with HIV] were left on their own, and we became their family members, their friends, because they were disowned,” says Marquez-Bhojani. In addition to being disowned, many patients also lost their significant others to the illness. “They had no support system.”
At the time of publication, 14 states had reported ethnic disparities in deaths compared to their population demographics.1 In Mississippi, for example, African-Americans comprised 72% of COVID-19 deaths, although only 38% of the state identifies as African-American.
Even today, people living with HIV still face stigma. “We never got over the stigma of it,” says Wooten. “Let’s not let COVID-19 be the same.” Like Marquez-Bhojani’s treatment on the subway, nurses were also stigmatized—both then and now. Daily, nurses report being harassed in grocery stores and coffee shops. While we have come a long way from the ‘80s, we still don’t know the full effects of any stigma that might come to be associated with COVID-19.
RACE AND DISPARITIES Like HIV fueling homophobia, COVID-19 has fueled discrimination against Asian-Americans, nurses and doctors among them. Both diseases also have a serious impact on other minority communities. “HIV and AIDS started out as a gay, white male disease,” says Martin. “But now four decades later, it’s predominantly in the African-American and Hispanic communities.” While ethnicity and race do not make someone more susceptible to either SARS-CoV-2 or HIV, the disproportionate impact reflects the outside factors that influence health, including access to care.
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As we move into a future where SARS-CoV-2 and COVID-19 may be as endemic as HIV and AIDS, we look to the past for guidance on issues we could soon face. “Confidentiality has been huge with HIV over the last four decades,” says Martin. “In the early years of the epidemic, you would not share your HIV status for fear of losing your job.” Wooten remembers how people were labeled by their status: “At first when someone was admitted, you didn’t put the diagnoses down. You didn’t let the insurance company know.” Confidentiality also complicates contact tracing. Martin says, “In the news I see a push for tracking as a way to prevent COVID-19 transmission. But is there a confidentiality issue with being infected with COVID? Is it similar to HIV infection?” Another parallel and hope for the future appears in the value of testing. “With HIV, the federal government has set a goal for people to know their status,” says Martin. “They’ve recently come out with home tests. We’re also seeing this push with COVID testing, drive-through testing, or whether a home test will be available.” However, Martin stresses that follow-up to testing with a health professional is key. In the HIV field, that means helping people with the virus receive anti-retroviral therapy to get to an undetectable viral load, while also helping people without the virus prevent transmission. “With HIV, we now have PrEP, pre-exposure prophylaxis. Like prevention for HIV, now there are tactics for COVID, social distancing or isolation or facemasks.” Soon, a vaccine could help create herd immunity and reduce risk for much of the population.
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Our nurses are also more aware now of the dangers of caring for people with infectious diseases and basing their concerns on the science of how the virus is transmitted. This is one place where the two crises differ. “I don’t think we had health care workers dying from AIDS because they were taking care of people with HIV infections. Now you see that people taking care of patients with COVID are also dying of COVID,” says MarquezBhojani. Many nurses fear we are forgetting the lessons of HIV, particularly when it comes to protecting health care workers. Without PPE and rapid testing, nurses are at risk: “AIDS made us aware of our vulnerability,” says Wooten. “Nurses will adjust but they should not pay the price.” i REFERENCES 1. Hanlon, C., & Higgins, E. (2020). States Use Race and Ethnicity Data to Identify Disparities and Inform their COVID-19 Responses. National Academy for State Health Policy.
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PRACTICING REMOTELY
How Providers Have Adjusted to Using Telehealth During COVID-19
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Wide use of telehealth has been historically limited by lower reimbursement rates for providers, regulatory guidelines, and security concerns. In these changed times, however, telehealth has quickly become a new norm. AS THE COVID-19 PANDEMIC sweeps the world, a lot of media attention has been given to the patients admitted with this virus. However, across the United States, patients are still experiencing heart attacks, still need dialysis, and still rely on crucial medications to function. While some providers have had to temporarily close their doors under stay-at-home orders, other providers have been able to continue serving their community and patients with telehealth. First adopted in the 1960s to monitor the health of astronauts from the ground, telehealth has evolved steadily over the subsequent decades.3 Until now, wide use of telehealth was limited by lower reimbursement rates for providers, regulatory guidelines that vary state to state, and security concerns. However, with many Texans now unable or unwilling to come into the office, telehealth has quickly become a new norm.
QUICK TRANSITIONS “It has drastically changed,” says Mia Painter, DNP, APRN, FNP-C, who has been practicing for over ten years at San Marcus Family Medicine. Her organization already had established telehealth services integrated into their electronic health records, so they were able to shift nearly the entire practice to telehealth quickly. “Prior to COVID-19, we were doing telehealth education for diabetes management. We reduced glucose levels in our patients dramatically, and they enjoyed having access to care without having to come in.” Staff and providers at her clinic found it easy to transition. In a day, the clinic may see between 24-30 patients per provider with extended business hours to accommodate patient schedules. “We still have one nurse practitioner at the clinic for urgent hands-on evaluations, and we are doing drive-up testing for COVID-19,” Painter says. “Everyone
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else is doing virtual visits from home. We are trying to keep our patients out of health care facilities to reduce the risk of exposure.” At a rural family practice clinic in the Texas panhandle, Mary Hazel Brantley, DNP, APRN, FNP-C, says her facility has moved towards more telehealth but are still trying to accommodate patients who request an in-person appointment. “A lot of patients who need follow up are older, so it’s harder for them to install an app or use a smart phone,” she says. “Some patients, especially the younger ones, are more receptive about virtual visits and phone visits.” At the same time, Brantley has seen some older patients who are leery of seeing providers due to social distancing and exposure in clinics. When telehealth is an option, Brantley and her team may do just a phone call or use FaceTime since HIPAA requirements are currently more lenient. “We don’t have a portal yet. We are trying to find a way to use one platform through the whole clinic.” Both nurse practitioners say their clinics have made the transition easy for patients by letting them schedule the same way they always do. The nurse or doctor will then give them a call at the appointed time.
EASED RESTRICTIONS In the United States, telehealth is primarily limited by state legislation. While we have used the generic term “telehealth” in this article, in Texas, “telemedicine” is performed by or delegated by a physician—to an advanced practice registered nurse for instance—and “telehealth” covers any other provider, such as registered nurses. Under normal circumstances, telemedicine requires a provider-patient relationship formed through audiovisual technology. The COVID-19 disaster declaration waived the audiovisual requirement, allowing for audio-only services. On the federal level, the Office for Civil Rights has stated that they will not be enforcing HIPAA rules, so non-HIPAA compliant platforms such as Skype and FaceTime are permitted. Reimbursement can also complicate how nurses provide virtual health care. In Texas, an emergency rule requiring parity in state-regulated commercial plans means an insurer cannot refuse or
limit reimbursement for electronic services. However, the state only regulates select insurance plans, such as marketplace plans and some employer-sponsored plans. Texas Medicaid falls under similar rules, but not all codes are reimbursable. Medicare also allows some audio-only services and has lifted restrictions on patient locations. Unfortunately, regardless of the program, providers must determine if their billing codes are reimbursable by the specific payor and allowed through the specific platform.
IRREPLACEABLE VALUE Both Painter and Brantley concur that nothing can replace in-office visits. “You’re not able to fully assess the patient. You can’t listen to their lungs or feel their pulse,” says Brantley. “Some medical conditions do require a hands-on examination,” Painter agrees. “The provider must be diligent about what can be seen in telehealth and when the patient needs to come to the office.” On the other hand, telehealth makes health care accessible to people who would otherwise have to travel long distances, or even risk their health, to come to an in-office appointment. “It is allowing us to reach a larger portion of patients who would not have access otherwise,” says Painter. “I was able to see a patient who was stationed across the state without the patient having to travel for hours. I’m afraid if we go back to prior telehealth restrictions, we’ll cut off access to patients that need telehealth services.” As workplaces conduct more virtual meetings and become more accepting of teleworking, many predict a shift in work culture that would not have happened without COVID-19. The same may be true of telehealth as well. “At one time, if we were approached about telehealth, I wouldn’t have entertained the possibility of doing it,” Brantley says. “I work in a small rural hospital, which at one point lacked adequate funding to have equipment and software for telehealth, so I had to find creative ways to integrate telehealth into our current practice. But telehealth and virtual visits will continue to have a place in the future.” i
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MAKING ADVOCACY
HAPPEN The Role of the Association in Representing Nurses in Statewide Collaborations By Cindy Zolnierek, PhD, RN, CAE Chief Executive Officer of TNA
ADVOCACY RESONATES with nurses as a duty owed to their patients—to ensure they represent their patients’ wishes, speak out for their patients’ needs, and are responsive to changes in clinical status as required by our Code of Ethics. Some nurses also engage in individual advocacy efforts in the policy realm— voting in elections, developing relationships with policy makers, participating in nursing associations, and responding to prompts to engage legislators on immediate issues. The importance of the individual voice of a citizen, a voter, a nurse cannot be underestimated. However, it is very difficult to launch policy initiatives or policy change as one person. The most effective equation for policy influence involves uniting individual voices with an organized message, such as through a professional association. Texas Nurses Association (TNA) has positioned itself as the voice of Texas Nurses in the policy arena with a mission of empowering nurses to advance the profession. During the current COVID-19 pandemic, nurses have faced unprecedented challenges, and TNA has stepped in to make sure their concerns are heard statewide, particularly by collaborating with other organizations in Texas. From TNA’s longstanding engagement in policy—through representation on many governmental advisory groups as well as engagement with other stakeholder associations during legislative sessions—
TNA is recognized as the predominant representative for nurses in the state. Having this groundwork already established helped TNA pull together quickly with other Texas organizations.
The most effective equation for policy influence involves uniting individual voices with an organized message, such as through a professional association. TNA was one of 14 organizations invited to participate in the Texas Health Care Industry Strike Force on COVID-19; the only nursing organization invited to the table. In addition to health care associations, university systems, the Department of State Health Services, and representatives from the Governor’s office participate in meetings. This Strike Force has convened every Saturday morning since March 21 to address three goals: 1.
Enhance statewide cross-sectorial COVID-19 health care response collaboration
2.
Identify critical vulnerabilities that need to be urgently addressed
3.
Identify state regulations that need to be modified
Discussion topics related to these goals
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have included testing, supplies (personal protective equipment [PPE], ventilators, medications), supply acquisition and distribution processes, capacity issues (acute, critical, and long-term care), workforce and shortages, vulnerable populations (residential facilities and prisons), mass critical care guidelines, economic viability issues, and recovery phase considerations. The Strike Force has made two requests of the Governor: 1.
March 29: Request to adopt mass critical care guidelines based on standards and suspend penalties for following guidelines and permitting APRNs to prescribe CSIIs and sign DNAR orders (still pending action by Governor)
2.
April 4: Request to waive enforcement of some HIPAA provisions related to telehealth
Provider groups, including TNA, have been staunch advocates of the need for PPE at every meeting. In addition, TNA and Texas Hospital Association have collaborated on efforts to ensure the focus on bed capacity includes a corresponding focus on staff capacity to ensure patients occupying available beds have necessary human resources to provide care. TNA’s purpose has always been to listen to and respond to the needs of nurses. During this crisis, as providers are asked to work with limited PPE or even reuse
PPE, nurses have experienced unnecessary confusion, anxiety, and even anger in already stressful health care environments. Seeing PPE locked up without explanation of the supply shortage has led to nurses believing their employers did not value their safety.
The work of associations cannot be done without members, and the causes nurses care about cannot be championed statewide without associations. Both individuals and associations are essential to influencing policy.
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With the Texas Organization of Nurse Leaders and the Texas Board of Nursing (BON), TNA collaborated on a statement recognizing the uncertainty of the existing environment and stressing the importance of clear and consistent communication from nurse leaders and hospital administration as we confront this challenge together. TNA and the BON have gone on record supporting CDC evidence-based recommendations as we respond to the pandemic. TNA is also a Steering Committee member of the Texas Public Health Coalition (TPHC), which sent a letter to the Governor supporting a gradual approach to reopening the economy based on public health considerations and the latest science. The TPHC continues to monitor the evolving COVID-19 situation and consider implications for the legislative session, specifically the need for a strong public health infrastructure. The work of associations cannot be done without members, and the causes nurses care about cannot be championed statewide without associations. Both individuals and associations are essential to influencing policy. By supporting nurse interests and representing those interests statewide with nursing expertise and perspectives, TNA is committed to serving Texas nurses and the nursing profession as a whole. We are best able to serve when individual nurses engage in policy advocacy with us. i
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