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TEXASNURSING M A G A Z I N E ONE YEAR LATER How a Global Pandemic Changed Nursing
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 1
ISSUE 2, 2021 Volume 95, Number 2 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH COPY EDITORS: Serena Bumpus, DNP, RN, NEA-BC and Shanna Howard
BOARD OF DIRECTORS OFFICERS: Tamara “Tammy” Eades, DNP, MSN, RN, President eades@uta.edu
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
Amy McCarthy, MSN, RNC-MNN, NE-BC, Secretary amykoshy@gmail.com
Gayle Dasher, PhD, RN, ANP-BC, Treasurer gayle.dasher@christushealth.org Jeff Watson, DNP, RN, NEA-BC, Past President jeff.watson@ttuhsc.edu
DIRECTORS: Melinda Hester, DNP, RN-BC melhester@austin.rr.com
Donna Wallis, MBA, MSN, RN drwallis@baptisthealthsystem.com
VISION
Nurses transforming health
Patricia Freier, MSN, RN-BC, CPHQ pfreier@covhs.org
Ernestine "Tina" Cuellar, PhD, RN, PMHCNS-BC tinaatutmb@aol.com
Lucindra Campbell-Law, PhD, ANP, APRN, PMHNP, BC campbel1@stthom.edu
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.
CHIEF EXECUTIVE OFFICER: Cindy Zolnierek, PhD, RN, CAE
TNA DISTRICT AND PRESIDENT Dist.1:
Teresa Acosta, RN shadowmon@sbcglobal.net
Dist. 3:
K. Renee’ Yarbrough-Yale, DNP, APRN, ACCNS-AG, CDCES reneeyy@zoho.com; 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:
Terry Long, DNP, RN, NEA-BC, CPHQ President.TNAd5@gmail.com, tna5.org
Dist. 7:
Lisa Kelly lisakelly0212@yahoo.com, tnadistrict7@gmail.com
Dist. 8:
Patricia E. Alvoet, EdD, MSN, RN-BC pe.alvoet@gmail.com
Dist. 9:
Kimberly Curtin, DNP, APRN, ACNS-BC, CCRN, CEN, CNL kcurtin@mdanderson.org; 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 janice.miller@umchealthsystem.com Dist. 19: Anita Lowe, 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
Copyright 2021 © Texas Nurses Association
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Unmeasurable Loss
Nurses Who Have Died of COVID-19 in Texas
COLLABORATION & ADVOCACY
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PRACTICE, PPE, AND PRESS DURING THE PANDEMIC How TNA Empowered Nurses During a Unique Situation
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How TNA Represented Nursing During an Emerging Crisis
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Putting Wellness
Front and Center 22
Contents IN EVERY ISSUE
FEATURES
5
16
20
21
PRESIDENT’S NOTES
COMMUNICATING ABOUT COVID-19
One Year Later
How TNA Staff and Members Responded to an Evolving Challenge
EDITORIAL: FOUNDATIONALLY DISRUPTED NURSING STUDENTS
EDITORIAL: COMPETENCIES DURING A CRISIS
6 TNA MEMBER NEWS Awards, Kudos
The Impact of Limited Direct Care Training for RN Students During Pandemic Restrictions
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Meeting the Challenges of Coursework and Clinicals During Pandemic Restrictions
Read more at texasnurses.org. TNA members receive stories, news, and practice tips every Tuesday in the Check Up e-newsletter. If you haven't been getting your Check Up, see your email spam filter or contact us at tna@texasnurses.org.
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The words you use impact your patient’s health. The evidence is clear. Peer-reviewed studies demonstrate that patient-centered language builds trust, reduces stigma, and increases positive health outcomes. Learn more from evidence-based guidelines, talking points, and videos designed to support you in having productive and satisfying patient conversations at txpmp.org. Sign on before you sign off.
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President’s Notes Tammy Eades, DNP, MSN, RN
ONE YEAR LATER COVID-19 and Nursing IT IS HARD TO BELIEVE we have been in COVID-19 mode for more than a year now. As I reflect on the past year and on how nursing has changed, I think about the uncertainty that we faced, the fear, and the determination in the beginning. We, as nurses, jumped into the pandemic full force offering our help without hesitation because that is what we do. You took care of your patients through exhaustion, lack of PPE, and sometimes not knowing how your families were doing. We have seen many illness and deaths and still face a lot of uncertainty from COVID-19, but we have been there for each other. You have become the nursing voice for health care. I would like to take a pause to remember those nurses who lost their lives from COVID-19 as they took care of our families. They gave their all for the love of nursing. They will always be remembered in our thoughts. The Year of the Nurse, 2020, did not turn out like we had hoped, planned, and expected. The first quarter of 2021 found us still facing uncertainty. However, we have overcome many challenges and obstacles, and we will continue to meet the challenges of tomorrow. Looking forward, we are finding out what the new normal in our society will look like with distancing and masking in public and what the new normal will be in health care. The vaccines have been out now for a few months and as we see a decline in cases, more people are starting to get out as warmer weather and summer approaches. COVID-19 will always be an evolving challenge. There still is a lot of
COVID-19 will always be an evolving challenge. There still is a lot of uncertainty but one thing is certain: We as nurses will continue to be there on the frontline taking care of each other, our patients, and our families.
Looking forward we are finding out what the new normal in our society will look like with distancing and masking in public and what the new normal will be in health care. uncertainty but one thing is certain: We as nurses will continue to be there on the frontline taking care of each other, our patients, and our families. This is a time that we need to remember how far we have come over the past year.
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Please take time to take care of yourselves. Get out in the sunshine and feel the warmth on your skin. “Keep your face to the sun and you will never see the shadows,” as Helen Keller said. Just like the sun rising each morning, we will still celebrate our nurses each day of 2021. Thank you for all you do. Tammy i
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TNA MEMBER NEWS SPOTLIGHT ON YOU AWARDS 20 for 2020 Nurse Awards The Texas Nurses Association (TNA) and Texas Nurses Foundation (TNF) chose 20 outstanding nurses to be recognized during The International Year of the Nurse 2020-2021. The TNA Award Committee reviewed many applications and made recommendations to the TNA and TNF boards for final selection. The following TNA members are being recognized for their dedication, perseverance, and compassion during this exceptional year. Read more at texasnurses. org/20for2020. Elizabeth Asturi, Texas Health Presbyterian, Dallas Kit Bredimus, Midland Memorial Hospital, Midland Deniz Dishman, University of Texas Health Science Center at Houston Ana Drummond, Dell Children’s Medical Center, Austin Tonya Edwards, MD Anderson Cancer Center, Houston Marcus Foster, United States Public Health Service/CMS, Dallas Bobby Lane, Civitas Senior Living, Fort Worth Missam Merchant, University Health, San Antonio
Steve Cermak Sharron Coffie Zylo Corley Natalie Denson Felicita Garcia Adrienne Nicholls Johnson Cheryl Mart Jaya Mathai Teresa Ortiz Anissa Pesina Shirley Roberts Heidi Scarbrough Cheryl Thaxton
Texas has two new nurses in office after the spring election. Sally Derrick, BSN, RN, CPN, was reelected as the Carrollton Farmers Branch ISD School Board Trustee, with 39.62% of the votes. She currently serves as the board vice president. Derrick is a registered nurse currently employed by Children’s Health where she is the Craniofacial Team coordinator.
KUDOS Congratulations to Jim Allard, DNP, RN, NEA-BC, FACHE, for his appointment to serve on the LGBTQ Healthcare Leaders Community Committee for the American College of Healthcare Executives. Allard is currently Vice President of Nursing and Chief Nursing Officer at Medical City Children’s Hospital and Medical City Women’s Hospital in Dallas. He also serves on TNA’s Policy Council and is chair of the Workplace Advocacy and Practice Committee.
Erin Perez, DNP, APRN, ANP-C, AGNP-C, ACHPN, won a seat on the Live Oak City Council with 60.43% of the vote. Perez is an adult and geriatric nurse practitioner who subspecializes in palliative care and hospice. She is the vice chair of the Texas Palliative Care Interdisciplinary Advisory Council and serves on TNA’s Policy Council. Perez recently debuted her first book and interactive module for Goals Wishes, Advance Care Planning through the Nurses Care Hub Publishing with seven hours of continuing education. i
Liliana Mondragon, WellMed Medical Group, San Antonio Traci Murray, United States Public Health Service, Dallas Irene G. Rosales, United Independent School District, Laredo
DFW Great 100 Nurses Congratulations to the TNA members selected as part of 100 RNs honored by the Great 100 Nurses of Dallas and Fort Worth for being role models, leaders, community servants, compassionate caregivers, and significant contributors to the nursing profession. Lisa Mason Nicole Bessinger Joshua Bourgeois Cornelius Brewer-Bell Megan Brunson Mary “Molly” Case
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PRACTICE, PPE, AND PRESS DURING THE PANDEMIC How TNA Empowered Nurses During a Unique Situation
By Serena Bumpus, DNP, RN, NEA-BC
WE STARTED 2020 WITH EXCITEMENT, hope, and joy. It was The Year of the Nurse after all, which meant a year highlighting and celebrating the value of our profession. No one could have ever predicted that our excitement, hope, and joy would quickly turn into fear, doubt,
and tribulation. The value of the nursing profession was made known but not in the way we imagined. As I reflect on the last year, COVID-19 highlighted our best moments. As demonstrated by our media requests and public support, the pandemic showed the world
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the value nurses hold on the health care team and what we bring to the table. However, as reflected in our practice calls and livestream Q&As, the past year also highlighted opportunities to improve our health care infrastructure and provide better ways to support our nurses.
In previous years, the practice line saw a few calls each month. In 2020 though, more than 300 practicerelated inquiries came in from across Texas. A DIRECT LINE TO NURSES The TNA Practice Hotline is available to all nurses across the state when they have general practice questions, concerns, or just need advice. In previous years, the practice line saw a few calls each month. In 2020 though, more than 300 practice-related inquiries came in. Nurses expressed confusion around legal protections, had questions about Board of Nursing discipline, sought resources for nurses diagnosed with COVID-19, asked how retired or inactive nurses could return to practice, and inquired about the vaccine.
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TNA's practice line allows nurses to share their challenges directly with TNA. Practice calls revealed two key areas where nurses needed support: (a) navigating nursing peer review, particularly invoking safe harbor and (b) understanding how to protect themselves in their workplaces. Even with jurisprudence education required by law, many Texas nurses do not understand nursing peer review laws, including direct care nurses and nurse leaders. To remedy this, we published weekly practice tips on safe harbor, safe staffing, and the peer review process. Understanding the steeper learning curve in areas outside of the hospital setting—such as long-term care and home health—we did additional outreach to offer education. The need for workplace protection was highlighted early in the pandemic as a lack of PPE across the state left nurses vulnerable to contracting COVID-19. In addition, when ill with COVID-19, many nurses had to take accumulated time off or unpaid leave, in addition to paying expensive medical bills. Nurses faced barriers to getting workers’ compensation because they could not “prove” they contracted COVID-19 at work. To protect nurses, TNA partnered with Representative Joe Moody on HB 396, which establishes a presumption that COVID-19 was contracted in the workplace, there-
Along with this new visibility in the press, social media offered a direct view into nursing practice. by ensuring nurses exposed to COVID-19 in the workplace are eligible for benefits.
A PLATFORM TO EDUCATE While nurses relayed their experiences to us, TNA represented nursing to the public. Prior to the pandemic, nurses were only quoted in 2% of health news stories, but over the last year, TNA has received hundreds of media inquiries.1 Print, television, radio, podcasts, and social media all vied to promote the value of nurses and educate viewers, readers, and listeners about the important role nurses play on the health care team. However, though we had the attention of the media, it was difficult for reporters to gain access to nurses on the frontline. Due to the quick turnaround of press requests, hospitals often draw from a prevetted list of doctors or administrators that rarely includes nurses. Bureaucratic red tape inside health care organizations also prevented the media from gaining access to nurses, leading some nurses to offer information anonymously. We realized that for health care to be portrayed accurately, employers must include nurses in media opportunities. Nurses are the most trusted profession and can use the media as a platform to teach.2 Over many months, TNA worked with major health care organizations to ensure nurse voices would be more prominent. We hope to partner with even more organizations and their media relations teams to better respond to future requests.
A WINDOW FOR THE PUBLIC Along with this new visibility in the press, social media offered a direct view into
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nursing practice. For many months, nurses posted videos of their patients getting discharged or photos of helping a patient through their last moments. Then, nurses were overcome with excitement and hope in December as the vaccine was distributed. This was the first step toward ending the COVID-19 pandemic. Nurses again posted videos and photos on social media, and vaccines began to trend across all platforms. As health care workers received their first doses, photos flooded social channels. The joy, the tears, the strength, and the enthusiasm of nurses and other health care providers getting their vaccines demonstrated the beginning of the end of the pandemic with #IGotTheShot and #ThisIsMyShot. With each post came comments from the public, many vaccine-hesitant but others swayed by seeing nurses proudly getting vaccinated. The past year demonstrated the critical role nurses played and continue to play in controlling this pandemic. The Year of the Nurse was one for the history books, and Texas nurses have a lot to be proud of. Texans are fortunate to be cared for by some of the most talented individuals in the profession. i REFERENCES 1 Mason, D. J., Glickstein, B., & Westphaln, K. (2018). Journalists’ Experiences with Using Nurses as Sources in Health News Stories. The American Journal of Nursing, 118(10), 42–50. 2 Saad, L. (2020, December 22). U.S. Ethics Ratings Rise for Medical Workers and Teachers. Gallup.
If you have practice-related questions, don't hesitate to call our practice line at 512-452-0645 ext 132.
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Unmeasurable Loss By Shanna Howard
IN THE MONTHS SINCE THE OUTBREAK of the COVID-19 pandemic in March of last year, nurses have sacrificed a lot. They have put in long hours—often with inadequate staffing—while battling with fatigue and exhaustion. They have lost time with their families and loved ones. They have dealt with stress, trauma, and the effects of the pandemic on their mental health. They have worried about exposure to the coronavirus both for themselves and their families. Because of the nature of nursing—providing direct care with close proximity to patients—nurses have seen the most risk of exposure, hospitalization, and death. In the early months of the outbreak in the United States, those in nursing-related occupations accounted for 36% of the health care workers hospitalized for COVID-19.1 Nurses account for 32% of COVID-19 health care worker fatalities in the United States.2 Health care workers are three times more likely than the general public to become infected with COVID-19, and minority health care workers are disproportionately impacted.3 More than 2,200 nurses worldwide lost their lives to COVID-19.4 As of press time, more than 1,150 U.S. nurses had died due to COVID-19.2 Yet, all of these numbers fail to capture the magnitude of the lives lost. The value they added to their teams. The years of care they could have provided. The families and friends they left behind.
Nurses have taken on so much of the burden of COVID-19, and they keep showing up for their patients day after day. We have so much gratitude for that dedication and care, and we mourn so many lives lost. Here we honor the Texas nurses who passed away due to COVID-19. i Editor’s note: All names were submitted by the public or taken from Lost on the Frontline, a partnership between The Guardian and Kaiser Health News. Names were not vetted for active licenses. REFERENCES 1. Centers for Disease Control and Prevention. (2020, October 30). COVID-19– Associated Hospitalizations Among Health Care Personnel — COVID-NET, 13 States, March 1–May 31, 2020. Morbidity and Mortality Weekly Report. 69(43): 1576–1583. http://dx.doi.org/10.15585/mmwr.mm6943e3 2. Guardian & Kaiser Health News. (2021, April). Lost on the frontline: Thousands of US healthcare workers died fighting Covid-19 in the first year of the pandemic. We counted them and investigated why. https://www.theguardian.com/us-news/nginteractive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcareworkers-deaths-database 3. Nguyen, L. H., Drew, D. A., & Graham, M. S. (2020, September 1). Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. Lancet Public Health 2020, 5(9): e475–83. https://doi.org/10.1016/ S2468-2667(20)30164-X 4. International Council of Nurses. (2021, January 13). The covid-19 effect: World’s nurses facing mass trauma, an immediate danger to the profession and future of our health systems. International Council of Nurses Covid-19 Update. https:// www.icn.ch/news/covid-19-effect-worlds-nurses-facing-mass-trauma-immediatedanger-profession-and-future-our
Nurses Who Have Died of COVID-19 in Texas Comments are presented as submitted with minimal edits.
Milagros Abellera, RN, San Antonio “She was the light in the darkness. I miss her every day. Mila passed away May 13, 2020; she fought for a month and a half. She touched so many nurses and was a mother to all in San Antonio. Every year in May, Mila would dress in an old nurse’s outfit with the dress, stockings, and hat for her shift to honor Florence Nightingale.”
Lauren Schoepf, 32, Lubbock
—Megan Jackson, RN
“She was a beautiful and wonderful school nurse.”
Eric Chavez, RN, 34
Kelly Balser, 50, Katy On September 4, Kelly Balser, devoted wife, mother, and Morton Ranch High School nurse, lost her battle with COVID-19. She leaves behind her husband Mark, daughter Halee, son Lance, extended family, friends, and countless students who she has cared for during her 22 years of service in Katy ISD.
Sherry Critz
—Dora Gonzalez
Marco De Leon, RN, Brownsville “Marco went to New York to help and died in New York.”
Jerome Arceneaux, 50, Houston
Harry Berryhill, 68
—Michelle Flores-Perez
Robert Armstrong, 56, Lubbock
Me’Lisa Caples-Bridges, 52, Houston
Karla Dominguez, 33, El Paso
Lynn Carter-Crump, 59, Henderson
Carlos Garcia, LVN, Brownsville “He died in his hometown hospital that he worked for over 30 years. RIP my dearest friend.” —Michelle Flores-Perez
Anonymous friend in DSPACU at UMC Lubbock
Carrie Avila, 43 “We lost our fellow sister nurse Carrie Avila. She was a beautiful, dedicated nurse for over 20 years.” —Jenn Valdez
Jessica Cavazos, 44, McAllen
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Jason Garcia, 42, Corpus Christi Russell L. George, MSN, RN
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Lorenza “Lori” Guerrero, RN, McAllen "Lori was an RN for more than 50 years at McAllen Medical Center Hospital. She lost her life to COVID-19 at the very beginning. May the Florence Nightingale lamp shine bright on Lori Guerrero and on all the nurses who lost their lives in the line of nursing duty during the COVID-19 pandemic. May all RIP. Amen.” —Yolanda Zarate Stephanie Hatton, 51, Granbury Charlotte Hayes, 60, Richardson Susan Heftie, RN, 67 (retired)
Iris Meda, 70, McKinney
Nichelle Tukes, LVN, 46
Nancy Nell, LVN Ruth Noemí Olvera, 50, Laredo Juan Rosas, LVN, 47 “He was an amazing nurse, and everyone loved his positive energy and loving and caring soul. He is very much missed by family and friends.” —Valerie Morales
Monnie Williams, APRN, 64
Ruth “Elsa” Spillers, 59, Poteet
Donna Holloway, 67, Trinity Freddie Johnston, 73, Abilene Tricia Lynch-Moten, 49 Malinda Mahan, RN, 63 “She was an amazing and funny woman.” —Sherron Meeks
A longtime employee of Methodist Hospital in San Antonio, she also worked in other areas of Texas. She leaves behind her husband Larry, daughter Mandy Sprado, and grandson. "She was a terrific nurse and the best emergency nurse!” —Mary Leblond Rodolfo Solano, 50, Harligen
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We express our sincere gratitude for your dedication and care, and we mourn so many lives lost.
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If you have received: Letter of Investigation from the Texas Board of Nursing Notice of Peer Review
Joyce Stamp Lilly RN JD Registered Nurse and Attorney
713.759.6430 jslilly@me.com www.nurse-lawyer.com
Get Involved BECOME AN ISSUE ADVISOR T EXA S PEER ASSISTANCE
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If you, a coworker, or a family member need help with a substance use or mental health issue, call the Texas Peer Assistance Program for Nurses. TPAPN case managers provide guidance, support, and monitoring to help nurses recover and maintain their licenses. And TPAPN peer advocates provide an empathetic listening ear. You and those you care about are not alone! Recovery is a lifelong journey, and TPAPN can help you get on the path.
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Find a way to engage that works for you! Issue advisors are Texas Nurses Association members who volunteer their time for short opportunities. You could be an expert on a topic, have lived experience, or simply have a personal interest. Previous issue advisors have helped create policy documents, write practice articles, or develop mobile content. Volunteer just for what you are comfortable with. Think that TNA has missed an opportunity to address a particular health issue, nursing practice topic, or a social issue? Tell us, and help us meet your needs and the needs of the modern Texas nurse.
We hope to work with you very soon! texasnurses.org/involved
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COLLABORATION AND ADVOCACY How TNA Represented Nursing During an Emerging Crisis By Cindy Zolnierek, PhD, RN, CAE, and Serena Bumpus, DNP, RN, NEA-BC
IN 2020, AS WE USHERED IN a new decade and welcomed the Year of the Nurse, we also greeted a not-so-welcome visitor, now known as COVID-19. The new year introduced a new normal marked with anxiety, fear, and confusion as health care professionals struggled to understand and respond to this novel and threatening invader. As guidelines from disease experts were uncertain and indefinite, and shortages of personal protective equipment (PPE) were anticipated and experienced, infection control practices on the front line shifted rapidly—often with little to no forewarning. Nurses questioned the evidence underpinning new practices, such as limiting and reusing PPE. Uncertainty led to mistrust at a time when nurses needed unity to fight the escalating threat of coronavirus.
While the frontline pulled together to establish strong clinical teams—armies to fight the invading virus— TNA united with partners across the state and country to make sure nurses had a voice. As their workplaces rapidly changed, nurses were being left out of the conversation, while also being among the most affected and at-risk professionals involved in the COVID response. Texas Nurses Association (TNA) approached this issue in two ways: by advocating for nurses and by collaborating with other health care entities.
STRENGTHENING NURSE WORKPLACES Staffing shortages, PPE shortages, lack of education, and miscommunication abounded in the early days of the
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pandemic. In early March, TNA put out a primer on how nurses could protect themselves in the workplace and informed nurses of their rights to expect a safe work environment and their rights under the nursing peer review law. TNA also called on leaders to support their frontline staff, rely on national guidelines and recommendations, provide accurate information, acknowledge anxiety and stress, overcommunicate, and support staff with presence and caring. Staffing shortages necessitated new models of interprofessional staffing to maximize existing resources,
TNA insisted on the inclusion of nurses on COVID-19 task forces established by local and state entities. and leaders had a responsibility to protect their staff from exhaustion, burnout, and moral distress. To recognize the strain nurses were under, TNA joined with the Board of Nursing and the Texas Organization of Nurse Leaders to issue a statement of appreciation, support, and encouragement to nurses providing direct care and leadership. Many nurses shared that they felt this statement finally acknowledged how hard they were working. As nurses adapted to their new COVID-19 work environments, they soon shared new collaborative practices, protocols, and guidelines they developed, and TNA distributed the information widely.
MAKING NURSING VISIBLE While the frontline pulled together to establish strong clinical teams—armies to fight the invading virus—TNA united with partners across the state and country to make sure nurses had a voice. TNA insisted on the inclusion of nurses on COVID-19 task forces established by local and state entities. As the only nursing organization invited to participate in the Health Care Industry COVID-19 Strike Force, TNA pushed for public health measures to prevent the spread of the virus, secure adequate PPE to protect frontline workers, adopt mass critical care guidelines, plan for surge staffing, and establish waivers to meet patient care needs. In addition, as a member of the Texas Public Health Coalition Steering Committee, TNA joined forces to support public health safety measures to slow viral spread, improve contact tracing, and increase public health funding. TNA
worked with the Texas Medical Association, Texas Hospital Association, and others to address visitation for patients and residents facing end-of-life and serious illness situations. We also teamed up with our established partners and made new partnerships to advocate directly to state officials and lawmakers on the PPE shortage, health insurance, waivers for health care professionals, and other urgent issues that would affect Texans’ access to care and health outcomes.
CONTINUING THE WORK As we move well past the one-year mark of this pandemic, TNA continues to represent nurses and nurse interests through an advisory seat on the Texas Expert Vaccine Advisory Panel and at the Capitol during the 87th Legislative Session. Through the Nursing Legislative Agenda Coalition, TNA has partnered to further policy that advances nursing and helps the communities we serve, such as through telehealth access, medicine accessibility and payment, broadband access, support for school nurses, benefits for nurses infected by COVID, and barriers to APRN practice. COVID-19 created new opportunities for team building and leadership on the frontline as well as collaboration and innovation at the state level. All crises present opportunity and threat. As we overcome the threat, we hold on to the lessons learned, including relationships built and strengthened that will enable collaborative practice at all levels to continue well into the future. i
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Communicating about COVID-19 How TNA Staff and Members Responded to an Evolving Challenge
T E X A S N U R S I N G M AGA Z I N E | I S S U E 2 , 2 0 21
By Kanaka Sathasivan, MPH
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remote work COVID-19 webpage guide to mandatory overtime return to practice transition from work to home town halls Facebook live events podcast COVID-19 email updates COVID-19 Task Force database of nurse speakers media interviews donations appreciation
WHEN LOOKING BACK ON THE LAST YEAR, the first few days and weeks of the pandemic are still a blur. In February 2020, Texas Nurses Association (TNA) staff were keeping an eye on the small novel coronavirus outbreak that had led to a handful of cases in the U.S. Our communication with nurses was minimal at the time, with a mention on COVID-19 alongside flu and cold prevention, then a brief overview of workplace safety in early March.
With very little information on how the virus spread and aware there was a high probability it was already in Austin, our staff made plans to move to remote work. Starting March 13, I was the first person to work from home, so I tested how the virtual private network and phone system could work; we needed extra devices and software. More than half our staff only had desktops, so the transition took several days to source laptops, update them with the required software, and help staff get set up. Amidst this change, our communications department was short a staff member for the first month, and we had just hired a new director of practice, Serena Bumpus, DNP, RN, NEA-BC. Both of us were trying to rapidly digest all the information about COVID as it came out.
COVID-19 CONTENT FOR NURSES Between learning about the virus and changing our work processes, it took nearly two weeks to get our COVID-19 webpage up—a joint effort by TNA and Texas Nurses Foundation—and it was just in time, as new information soon came pouring in to be added to the site. We coalesced information from the Texas Department of State Health Services, waivers from the Texas Board of Nursing, and declarations from the Office of the Texas Governor into an organized page where nurses could find everything they needed. We also determined what information nurses needed that did not exist currently. Our chief executive officer, Cindy Zolnierek,
PhD, RN, CAE, wrote a guide to mandatory overtime that rapidly amassed thousands of views. Other content covered how to return to practice after retirement, how to safely transition from work to home to prevent family members from becoming infected, and ethical considerations during the pandemic.
To keep nurses informed and to learn more about their experiences, we held town halls and Facebook live events; the recordings were transferred to our podcast for increased accessibility. We also started sending regular COVID-19 email updates to our full database, members and non-members alike, to reach as many nurses as possible. As we had only a few staff working on COVID, we realized that we needed a more reliable way to determine what issues were of most importance to nurses. In July, we established our COVID-19 Task Force, deliberately finding nurses from a multitude of practice areas—long-term care, discharge planning, school nursing, and many more. The task force provided insight into the situation on the ground across Texas, and they helped staff develop even more materials to flesh out the COVID-19 webpage. In early November, our collective efforts on COVID-19 were recognized with a Platinum Award for Crisis Communications from MarCom.
NURSES IN THE SPOTLIGHT The press and media, who normally only seek comment from nurses on policies that directly affect nurses, were now reaching out for health information, scien-
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growth
resilience Above all, we have seen how nurses always prioritize their patients.
tific questions, and patient advice. Nurses were thrust into the spotlight—ironically in the year that the World Health Organization declared to be the Year of the Nurse—and their expert opinions held new weight with viewers and listeners. Where we once did a dozen interviews annually, in 2020 we gave more than 130 interviews on COVID-19 alone and built a database of nurses to send requests to. Not only did our media presence increase visibility for nurses, it strengthened TNA’s relationship with media outlets, which now had another health organization to ask for comment; soon our non-COVID interviews increased as well. We also vetted dozens of organizations who wanted to donate to nurse efforts, show their appreciation for nurses, and provide free services. With some of the donated funds, we were able to print yard signs for Nurses Month 2020 stating “Nurses Are Heroes.” The response was incredible, and many signs are still standing today, through the summer heat and the winter freeze.
T E X A S N U R S I N G M AGA Z I N E | I S S U E 2 , 2 0 21
Above all, we have seen how nurses always prioritize their patients. They have shared stories of holding patient hands when the family was not allowed to enter and stories of resilience as they saw more death in a week than ever before in their careers. Even one year later, our task force continues to develop new 1-pagers, and with the help of a partner, translate these documents into Spanish and Vietnamese to make sure as many Texans as possible get the information they need. Reflecting on the past year, it is easy to have many regrets. Why did we wait to urge the use of masks? Why did we focus so much on self-care and not enough on institutional approaches? Ultimately, we did the best we could with what we had. With a small staff working on COVID and a handful of volunteers, we created an award-winning campaign and a public presence to match that of doctors and other health care providers. We learn and continue to grow every day, and we appreciate all the nurses who have sustained our efforts and supported us this past year. i
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You take care of your patients. I’ll take care of your license. Yong J. An, Attorney Represented over 100 nurses before the Texas Board of Nursing since 2006 Former State and Federal Prosecutor State-wide nursing licensure defense practice
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Editorial : FOUNDATIONALLY DISRUPTED
NURSING STUDENTS
The Impact of Limited Direct Care Training for RN Students During Pandemic Restrictions By Katherine Kreis, MSN, RN
T E X A S N U R S I N G M AGA Z I N E | I S S U E 2 , 2 0 21
THE JOURNEY OF A PRE-LICENSURE NURSING STUDENT is a challenging path. Many students enter nursing school and are surprised by the profound lessons in character, determination, integrity, and courage, which are vital to the pursuit of a career in nursing. These are the lessons that shape their individual practice. Unfortunately, many of those come from reflecting on direct care experiences and have been greatly limited by the widespread events of this past year in response to SARS-CoV2. The impact of this pandemic on nursing education has been undeniable. Hospital clinical placements, which were already a challenge previously, became virtually nonexistent as facilities closed their doors to visitors and learners alike in the Spring 2020 semester. Many nursing programs like ours made a shift to virtual learning and care simulations to continue educating despite the difficult circumstances. Naturally, instructors in foundations (like myself) were concerned about the impact on the student’s skill level and competencies given their limited direct care experience. These foundationally disrupted nursing students (FDNS) experienced a critically timed impact upon their training. Their lack of previous experience combined with this decrease in direct care hours resulted in some unexpected challenges in later program courses. These students could move forward into acute care coursework, and yet the practical application of skill remained sparse. Student progress was permitted, per the state regulations, when students met the minimum number of clinical hours each semester. Many of these students had less than 50 hours of direct care practice before advancing again into critical care coursework. During the Spring 2021 semester, I also began teaching critical care level clinical students. This gave me the chance to observe these same students from foundations who had now advanced to the next year of the program. It was startling to see the impact of these lost direct care opportunities. These students were nearing the end of the program. Still, they were faced with challenges and fears common to the foundational student level such as difficulty with shyness in introducing themselves, difficulty with handoff communications despite training, and uncertainty in the process for medication administration and client teaching. The profound loss of communication skills, role awareness, and confidence was demonstrated in a significantly delayed skill level. Even though clinical placements continued to be restricted for many students nationwide, this group did receive the opportunity for direct care practice in an acute care unit. With these additional days of hands-on training, the students were able to adapt and demonstrate the required skills. Unfortunately, not all FDNS will have similar opportunities or sufficient direct care experience before graduation. As we prepare for these students to enter the workforce in the upcoming months, we must prepare for the likelihood of significant deficiencies in the practical application of skills. Perhaps now is the time for us to consider implementing a required residency program for nursing graduates, like other health care professions have done. i
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Editorial : COMPETENCIES
DURING A CRISIS Meeting the Challenges of Coursework and Clinicals During Pandemic Restrictions By Kayla Hoang, Texas Nursing Students Association President
IT IS UNBELIEVABLE TO THINK that we experienced a pandemic during our lifetime, and it has been over a year since it started. Although we are finally in the recovery and healing phase, the damage caused and the lives taken will forever impact our generation. The start of the pandemic hit while I was in the first semester of nursing school. In February 2020, everyone spoke about how this virus was rapidly spreading throughout China. We naively thought we were protected by distance. Soon domestic reports started making the news, and within a few months, our affected numbers grew exponentially. Our spring break happened as planned, but then one week turned into two. The next thing we knew, a mass email informed us the remainder of the semester would be virtual. Virtual nursing school? How was that going to work? From day one, we were told that as nursing students and soon-to-be registered nurses we needed to be versatile, flexible, and understanding. Little did we know, those skills were going to be instilled in us very quickly. The amazing staff and faculty at Texas Woman’s University worked tirelessly and round-the-clock to seamlessly transition our face-to-face curriculum online. Syllabi had to be changed, exams were moved, due dates were extended, and—the hardest change to accept—in-person clinicals were canceled. As nursing students, face-to-face patient care is what we look forward to most. Our hands-on skills now had to be acquired through virtual simulation and endless practice. Going into the second semester, expectations were low, but hopes were high. COVID numbers were soaring in Texas, so countless hospitals refused student nurses; again our school worked a miracle. We got clinical experience, but we had to be willing and able to drive anywhere and be ready at any time. Our group’s adult health clinical was in the Texas Medical Center, and our women’s health clinical was in the Woodlands. Those 12 weeks were indescribable, and I attribute having amazing clinical experiences directly to our clinical faculty.
Through this pandemic, we have become fiercer, smarter, and more resilient; and that is what the future of nursing has to look forward to. The current spring semester has been the most difficult one yet. It is our heaviest load with three classes and clinicals: Child Health, Adult Health II, and Mental Health. Everyone talks about how challenging nursing school is, but no one mentions the mental toll it takes. Self-care takes a back seat to the priority of nursing school. The week begins with classes from 9 a.m. until 5 p.m., usually followed by exams on Tuesday. Some of us then have 12-hour clinicals on Wednesday and Friday and a half-day clinical on Saturday. Many students also have families, jobs, and other responsibilities. It is hard to remember to prioritize ourselves, and oftentimes we forget. With the support of our cohort and faculty, we are successfully pushing through. In addition, nursing students face fear and uncertainty about having the skill and competency necessary to provide safe, successful care to patients. However, the pandemic enabled us to conquer any challenge thrown our way. We became our own advocates and absorbed as much information as we possibly could from our limited experiences. In my section, we sought out educational opportunities during rotations. If a nurse was preparing to perform a procedure or test we had never done, we would ask to observe and learn. Although our go-getter attitude opened the door, our nurses were the ones who encouraged and allowed us to expand our curiosities. Many would ask us what skills we had checked-off and let us take over patient care as appropriate. Without the willingness of some of these nurses, our confidence would not be where it is today. Through this pandemic, we have become fiercer, smarter, and more resilient; and that is what the future of nursing has to look forward to. i
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Putting Wellness
Front and Center
How the Texas Peer Assistance Program for Nurses provided support during an unprecedented year.
TEXAS PEER ASSISTANCE PROGRAM for Nurses (TPAPN) Director Dawn Webb, MSN, RN, PMH-BC, sums up her philosophy like this: “We model person-centered care.” From giving care to participants to supporting the interests of TPAPN case managers, this philosophy was put to the test during the COVID-19 pandemic. Rushed days of getting the team set up to work from home were filled with participant calls and keeping the Board of Nursing (BON) informed. TPAPN’s mission is to safeguard patients while providing help to nurses, and the past year truly demonstrated the passion of its staff and the commitment of its participants.
SELF-CARE EDUCATION Early in the pandemic, it became abundantly clear that burnout alongside trauma would be the next crisis in nursing. TPAPN worked diligently to get ahead of the curve, mailing tens of thousands of free self-care wallet cards, creating education on resiliency in nursing, and participating in an eye-opening panel with Texas Nurses Association (TNA): “Perspectives on Moral Distress and Self-Care.” TPAPN and TNA offered 41 Nurse Chat sessions during May, June,
“As we provide nurses with resources, we make sure we do our part for them to be successful. If they can take care of themselves, they can take care of other people.” and July, where nurses were invited to an open salon to process their experiences and emotions. In addition, Webb sat on the Strength Through Resiliency Committee of American Nurses Association Enterprise’s Healthy Nurse, Healthy Nation. Working with staff and mental health nurses from across the United States, the committee created online resources for mental health help and suicide prevention.
providing it to their employees, and she is also in discussions for a new partnership with a similar app that addresses alcohol use disorder and misuse.
PARTICIPANT ADJUSTMENTS
Similarly, Webb wrote about normalizing mental health among nurses and created a list of resources for Texas nurses, which was posted on the TPAPN and TNA websites. Another article appeared in the Texas BON newsletter titled, “Mental Health and Substance Use in Nursing: Nurses Caring for Themselves and Others.”
While Webb did outreach for the wellbeing of all nurses, her team worked to provide resources to participants. Webb and TPAPN case managers touched base with participants regularly to share resources for self-care, wellness, and support, and participants reached out on their own seeking guidance. “As we provide nurses with resources, we make sure we do our part for them to be successful. If they can take care of themselves, they can take care of other people.”
TPAPN and TNA also connected dozens of nurses with an evidence-based, digital therapeutics app called Deprexis at no cost to help them manage mental health challenges. Webb hopes that health care organizations will consider
One major change was in the drug testing process. During the early days of COVID-19, Webb and her team decided to make sure nurses felt safe in getting drug tested. “We approved a lot of nurses to omit drug testing until the testing sites set
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up protocols for safety and prevention. This decision was to protect nurses and their patients.”
EMPLOYER RESPONSIBILITIES While self-care and personal resiliency are vital to a nurse’s success, they can also be a burden on the nurse. TPAPN’s primary goal this year was to make selfcare easy. However, nurse leaders and employers have a crucial role to play.
“Unless nurses pull together, one person won’t be able to make a difference. Create a workgroup or committee. It’s OK to ask for what you need.”
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ON TARGET. MSN . DNP . POST-MASTER’S . PhD
“Employers must invest in their team and provide supportive environments,” Webb emphasizes. “Communications. Transparency. Growth. Support nurses in their own personal goals.” TPAPN models this, for instance by supporting team members’ ambitions—whether in learning more about motivational interviewing or pursuing higher education.
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Webb encourages nurses to pull together to ask their employers for the support they need. Consider if complaints or requests are going to the right person. Put thought into a proposal, be specific about what you want, and present a unified front. “Unless nurses pull together, one person won’t be able to make a difference. Create a workgroup or committee. It’s OK to ask for what you need.”
Distance and hybrid learning
Moral distress from low staffing and overworking is a common complaint. Many nurses are leaving the profession altogether. Webb stressed the role of nurse leaders: “Nurse leaders need to advocate, fight for their team. Make an environment where everyone has trust, needs are being met, and everyone gets a lunch break—staff will be happy to come to work and stay longer, meaning less turnover. Invest in staff upfront so they are invested in the organization.” As her team can attest, she practices what she preaches with TPAPN. “I’m not going to put business before their everyday needs. The only way this business will run is if my team is happy and healthy.” i
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