It will take time for the toll of the pandemic to be fully quantified, but stories abound. Nurses in COVID-19 hot spots across the country have been asked to do the unimaginable. They have pushed body and mind to the limit to save lives when they could and have supported families and patients when sustaining life became impossible.
As of early March, more than 3,500 health care workers had died of COVID-19 in the United States alone, according to Lost on the Frontline, a project of Kaiser Health News and The Guardian. Of the 1,693 whose occupations are known, 542 were nurses. Like other clinicians, nurses have experienced workplace hardships and faced moral dilemmas this year, in addition to the well-documented stresses they face daily as health care providers. Yet, the pandemic has also spurred changes in the work environment and to practices and regulations that many nurses have advocated for. Despite the significant challenges associated with being a nurse during the pandemic, this may be a favorable time to enter the profession.
MORE COLLABORATION AND INNOVATION
Megan E. Brunson, MSN, RN, CNL, CCRN-CSC, immediate past president of the American Association of Critical-Care Nurses and the night shift supervisor in the cardiovascular ICU at Medical City Heart Hospital in Dallas, says nurses are working in a more collaborative environment than was previously the norm. “Before, nurses that were new to the profession were kind of like, ‘Oh, do I have the ability to say this? Do I have the ability to contribute?’ and now it's just standard,” she says.
The pandemic has also created an environment in which innovation and the free flow of ideas are prized, she adds, whether they come from nurses, physicians, respiratory therapists, or others on the team. “It's just an openness to find the solution that best fits the patient or the team. And then, if it works, ‘How can we emulate that on another unit that might have the same problem?’” Brunson explains. “The pandemic has allowed us to make innovation a staple in our practice. That professional growth is what nurses are so excited about.”
An August 2020 survey of 4,000 people, 1,000 of whom were nurses, commissioned by Johnson and Johnson in partnership with the American Nurses Association and the American Organization for Nursing Leadership, affirms Brunson's observations. “Despite the incredible challenges posed by COVID-19, the crisis has resulted in some progress within the profession, accelerating changes in attitudes and expectations regarding nurses,” the survey summary's authors write. Specifically, surveyed nurses who spent more than half their time caring for people who had COVID-19 were more likely than those who spent less than half their time with COVID patients to be satisfied with leadership opportunities at work. These included opportunities for professional advancement, to lead programs or initiatives, and to influence decisions about workplace organization. They also said they were more satisfied with the chances they had to work on collaborative interprofessional teams.
PRACTICE BARRIERS REMOVED
Practice has also improved for some advanced practice registered nurses (APRNs), with many states removing barriers to practice during the public health emergency. According to the American Association of Nurse Practitioners, 21 states temporarily suspended or waived some requirements for practice agreements between NPs and physicians. On January 1, Massachusetts went a step further, becoming the 23rd state to allow NPs to practice independently.
At the federal level, the U.S. Department of Veterans Affairs (VA) issued guidance in April 2020 allowing its certified registered nurse anesthetists (CRNAs) to practice without physician supervision during the pandemic if they were licensed in a state that allows such practice. CRNAs had been excluded from the VA's 2016 rule authorizing APRNs to practice to the full extent of their education and training in VA facilities, regardless of state laws. Additionally, the March 2020 passage of the Coronavirus Aid, Relief, and Economic Security Act allowed NPs, clinical nurse specialists, and physician assistants to order and certify Medicare home health services, previously a cumbersome, multistep process requiring physician involvement.
According to Winifred Quinn, PhD, director of advocacy and consumer affairs at AARP's Center to Champion Nursing in America, this change is historic. “That was a permanent policy change that could affect a million or more people immediately every year,” she says.
The pandemic also prompted the widespread use of telehealth, jump-started by federal waivers of Medicare rules to allow all eligible providers to use the technology to deliver an expanded list of services. According to the Medscape Nurse Career Satisfaction Report 2020, which details findings of a survey conducted last August, 75% of NPs, 77% of nurse midwives, and substantial percentages of RNs, LPNs, and clinical nurse specialists used telehealth last year. This type of care was most often provided by clinicians working in outpatient settings and has been widely credited with ensuring access to essential care during the pandemic.
Efforts are underway in Congress to ensure continued access to telehealth services. However, during a February 2 virtual telehealth policy update from the Center for Connected Health Policy, its executive director, Mei Wa Kwong, JD, said she was skeptical all telehealth waivers put in place during the pandemic would become permanent. “I would not be surprised if there's maybe a little bit of a pullback from telehealth, that there's a little bit more scrutiny, a little bit more demand of evidence and data, going forward.”
Despite signs the pandemic has resulted in an enhanced practice environment for many nurses, there is widespread concern that nurse burnout as a result of caring for people with COVID-19 could ultimately lead to future nursing shortages. A 2020 survey of nearly 6,500 RNs working on medical–surgical units or ICUs in New York and Illinois found that, on average, 47% reported high burnout and 24% said they intended to leave their current job—and this was before the first case of COVID was reported in New York on March 1. Since then, burnout rates have increased according to the Medscape survey, which collected data from more than 10,000 nurses, most of whom had taken care of a patient with COVID-19.
California is not the nation, but with 12% of the U.S. population and one of the highest total COVID-19 hospitalization rates, its experience may be instructive. Every other year, the Healthforce Center at the University of California, San Francisco, conducts a survey of the state's nursing workforce for the California Board of Registered Nursing. The researchers have yet to analyze the 2020 data they collected, according to Joanne Spetz, PhD, associate director for research at the center, but they have reviewed 2,000 comments submitted by nurses between July and October. These illustrate how nurses are cutting their hours during the pandemic to care for children or signing on with travel nursing companies after being furloughed. Some nurses reported requesting leaves of absence or nonpatient care roles, according to Spetz.
“The nurse's job has suddenly become unstable, which is actually somewhat unusual,” says Spetz. “In the 2008 recession, we saw nurses, especially older nurses, increase their employment, and that was almost certainly because they were compensating for their spouses' job instability. I would not anticipate we're going to see big losses of the relatively newer entrants [to the profession], but those experienced nurses we have really relied on to help staff the specialty units and also mentor and prepare the new entrants, I think we have some reason to expect that we're going to lose them at a faster rate than we were expecting.”
Iona Folkes, MSN, RN, a staff nurse at St. John's Episcopal Hospital in Far Rockaway, New York, and contract administrator for 1199SEIU United Healthcare Workers East, has heard her coworkers talk of early retirement. But, as of February, she had yet to see them follow through. “We have nurses in their 70s still working. I'm asking, ‘What are you still doing here?’ and they're like, ‘Girl, I'm not ready yet.’ It's just that people love what they do, and when you love what you do, you don't see it as a burden.”
Michelle Mahon, RN, assistant director of nursing practice at National Nurses United, is also not seeing attrition in the nursing ranks. In fact, she reports the opposite. “We are seeing nurses who have extended their retirement to stand with their colleagues,” she says. “Throughout this crisis, we are seeing nurses who are desperate to help out.”
INCREASED INTEREST IN NURSING
These observations dovetail with rumors that the increased press coverage of nurses' work has increased interest in the profession. Whatever the cause, data gathered by the American Association of Colleges of Nursing show an approximate increase of 6% in the number of both applications and applicants to baccalaureate nursing programs in 2020.
Diana Mason, PhD, RN, FAAN, senior policy service professor and codirector of the Center for Health Policy and Media Engagement at the George Washington University School of Nursing, studies how journalists use nurses' voices in their reporting. She has heard talk that media coverage is attracting new entrants to the profession in droves but isn't convinced the influx will be sufficient to offset the number who will leave after a year or more of working under pandemic conditions. Her colleagues in the clinical world tell her, “Nurses are fleeing. They are saying, ‘I'm not going to keep doing this,’ and nurses who can retire earlier are retiring early. I think we are going to have a nursing shortage that's going to take a decade at least to reverse.”
The Medscape survey offers some support for these observations. Among RNs who expressed dissatisfaction with their decision to become a nurse (roughly the same percentage as in 2019), 23% said they would retire earlier than planned, up from 18% the prior year. One-third said they planned to pursue a new path within nursing. Moreover, 21% to 35% of respondents, depending on their nursing role, reported decreased career satisfaction as a result of the pandemic. This drop in career satisfaction was reported by 40% of nurses working in acute care settings and even higher proportions of nurses in long-term care and hospice settings. Despite these findings, 93% of RNs, 95% of LPNs, and equal or higher percentages of APRNs said they were glad they became a nurse.
The Medscape and Johnson and Johnson surveys were conducted in August, before most regions of the country had borne the full brunt of the pandemic. Whether potential nursing shortages caused by early retirements and career changes will be balanced by an influx of new nurses remains an open question. At a minimum, one clear outcome of the pandemic appears to be heightened public awareness of nurses' value and the challenges they face at work.
Mahon is hopeful this increased appreciation will give nurse advocates new allies. “As we continue to demand respect in our workplaces in the form of safety for ourselves and our patients, we will have broader support from the community, who now understands how important the role of nurses is,” Mahon predicts. “Our patient care conditions and our working conditions are one and the same, right?” she asks. “If we're not safe, our patients aren't safe.”—Nicole Fauteux