The Nurse Practitioner

Thursday, May 6, 2021

The role of an NP during unprecedented times

Jill Muhrer, DNP,FNP-BC, is a certified family nurse practitioner at Cooper University Health Care's Early Intervention Program in Camden, N.J. where she provides primary care to patients living with HIV. In honor of Nurses Week (May 6-12), she chatted with The Nurse Practitioner about what it means to be a healthcare clinician in these unprecedented times.

What does it feel like to be a healthcare provider in the middle of the COVID-19 crisis?

As an outpatient NP providing primary care to patients living with HIV, I've never felt prouder to be a member of the nursing profession than during the pandemic. I am deeply impressed by how nurses from all walks of life, some retired, have risen to the occasion and been able to provide high quality life-saving care to patients with COVID-19. From the bedside to the local, community, and national levels, nurses have shown their compassion, courage, and high-level skills in confronting COVID-19. This is despite multiple challenges that they face on a daily basis such as:

At the same time, uncertainty about the Covid-19 virus as well as fear of risk both to self and family members has caused confusion and anxiety making it a challenge at times to know how to protect others while staying safe. Add to that heightened concerns regarding PPE availability/feeling safe. Despite these concerns, it has been gratifying to care for others during this time of crisis.

What has helped you provide care and get through these tough times?

There are sources of help that made it easier to provide care such as collaboration with my team; developing protocols for diagnosis and treatment; coordinating care; and keeping a sense of humor. Hospital communications—daily updates, educational presentations/power points and a team to consult at the point of care with questions regarding current recommendations for Covid-19—have also been very helpful. As have resources through nursing organizations that provide up to date information.

Can you share any specific case or experience that made your efforts particularly gratifying during the pandemic?

Telehealth visits became the norm in our office for a while especially during lockdown. Ironically the show rates for these visits was much higher than the 50-60% average show rate in our practice. One of my patients was notorious for “dropping out of care" for months, even years. He would call in for refills, promise to get labs done and to come in for an appointment if we refilled his medications “one more time". He would usually wait until we were unable to refill his meds and then possibly show up. With telehealth visits, everything changed. He appreciated not having to come in as he not only worried about the stigma of attending an office providing care to patients with HIV(which was strictly confidential), but was also terrified of contracting COVID-19 and rarely left his house. When offered a telehealth visit he rapidly agreed but insisted that it be telephone only. He didn't want anyone seeing his house. This all changed when he got a rash. He finally agreed to use the video/camera feature so I could address his rash.

It was fascinating that once he overcame an initial fear of the video aspect, he absolutely started to love it. He showed me his artwork, introduced me to his two dogs and was able to review all medications virtually. We also diagnosed and treated his rash successfully. The connection between us strengthened rather than becoming more distant. We found a convenient location to get his labs near his home that involved minimal risk so he was able to easily get his diagnostic studies.

He is now available for his health visits consistently and prefers the camera feature. He loves telehealth and wants to continue with it. This will not interfere or replace his once-yearly visit in the office – it will supplement them in a meaningful way for both of us.

What message do you have for policymakers who are navigating this crisis? Most states relaxed NP scope of practice laws during the pandemic, which may go back to the status quo after the public health emergency. What are your thoughts on this? Should states revisit expanding scope of practice permanently?

NPs have repeatedly demonstrated their ability to provide high quality evidence-based comprehensive healthcare to a diverse population of patients with acute and chronic health concerns. This has been further supported during the pandemic during a time of relaxed NP scope of practice laws when NPs improved access to lifesaving care for patients with COVID-19. All NPs should be supported by policies that enable them to practice at the full extent of their training and education. This is a critical time to advocate for legislative changes.

What are some of the challenges and barriers you've experienced during the pandemic?

Challenges included balancing in-office with telehealth visits; building trust in vaccines; and short staffing, increased stress, as well as increased mental health burden for providers, team members, and patients. Uncertainty regarding the virus and changing recommendations also posed hurdles as did communication with patients and helping them with the challenges of obtaining access to care.

What have we learned over the past year regarding the issues with US healthcare and what can we do to make the system more efficient and equitable?

We have learned that we must confront institutional racism and promote equal healthcare access for people of color (POC) especially with COVID-19 where the morbidity and mortality rates are higher in POC. We should support the American Association of Nurse Practitioners (AANP) commitment to “empowering all NPs to advance high- quality, equitable care while addressing healthcare disparities through practice, education, advocacy, research, and leadership (PEARL). “ One way they suggest doing this is through the development of a task force to focus on problem solving and through collecting data to prioritize resource placement. There is also a U.S. Department of Health and Human Services sponsored COVID-19 Community Corps that people can get involved with.

During an unprecedented time such as this, while fighting a deadly pandemic, nurses should remember that self-care is important too. What should nurses and NPs do to ensure their mental and physical health during such a time?

Coordinating with each other on policies, protocols, and strategies
Trying to take breaks throughout the day even if short, to take walks, talk, or just sit quietly
Use consistent times to decompress, go over cases with others
Team approach to exercise, sharing diet tips /recipes
Humor and creativity; innovations

What can seasoned NPs and APRNs do to engage with nursing students and those in their early careers to help them grow to their full potential as healthcare providers?

Offer to be clinical preceptors
Provide mentorship
Participate in career day opportunities

Anything else you would like to add that wasn't touched on in the previous questions?

Importance of continuing scientific research that informs clinical decision-making and advances clinical care especially during the pandemic when there has been so much confusion, uncertainty, and fear. Use this approach to advocate for full practice authority.
Developing and strengthening leadership skills by becoming involved at the local, community, and national levels in healthcare-related issues and policy making especially in creating equal access for POC for COVID-19 testing, treatment, and vaccines.
Writing and publishing articles related to practice, policy, clinical care, and research especially related to current issues with the pandemic.

Photo by Anna Shvets from Pexels

Wednesday, April 28, 2021

Empowerment, collaboration, and advocacy to address health inequities due to climate change

climate change pollution img.jpg While health inequities have always existed in US healthcare, they have become even more evident with the advent of the COVID-19 pandemic. Another area of concern to public health is the impact of climate change on our health, specifically, its disproportionate impact on low-income populations and people of color.

The health inequities caused by climate change as well as ways to address them via advocacy efforts was a focus of the Nursing Leadership in Climate Change and Environmental Health conference held by Jonas Nursing and Veterans Healthcare Program earlier this week.

Anabell Castro Thompson, an NP and Senior VP of Equity, Diversity and Inclusion at Equality Health, emphasized the many reasons for these inequities, including lack of access to green spaces in low-income neighborhoods with fewer trees and more heat-trapping pavements. These populations also lack quality healthcare and medicine, have poor household conditions and crowding, and face language and cultural barriers to health information. Residing in food deserts also means lower availability to nutritious foods. Additionally, lower socioeconomic status causes higher levels of stress and mental health conditions.

“The same physical, social, and economic environments that are associated with poor health outcomes also increase exposure and vulnerabilities to the health impacts of climate change," said Thompson. “These communities are often historically disenfranchised, they lack the political and economic power and voice to ensure that their decision-makers take their perspectives, needs, and ideas fully into account. The lack of power contributes to health inequities and constrains their ability to build climate resilience and to fully contribute to climate change solutions."

African Americans face a 150 to 200% higher likelihood of heat-related death, a 36% higher chance of contracting asthma, and are three times more likely to die or be admitted to the ED from asthma than non-Hispanic Whites. Native Hawaiians and Pacific Islanders are also more susceptible to asthma due to higher pollution in their communities, which exceed federal air quality standards. Similarly, Hispanic children are twice as likely to die from asthma and have increased risk of developing type 2 diabetes.

Hispanic communities are also disproportionately affected because of the regions in which they live—a majority of their population resides in the Southwestern US which is affected by drought and wildfires. They also largely live in pollution- and flood-prone areas, as well as urban heat islands. Nearly two million Latino individuals live within a half mile of oil and gas developments, which also leads to pollution-triggered health effects.

Latinos are also at risk because of the types of work many are employed in–according to a 2015-2016 National Agricultural Workers Survey, 83 percent of all farmworkers are Hispanic, and per the U.S. Bureau of Labor Statistics, 27.3 percent of construction workers in 2014 were Hispanic or Latino. Among agricultural workers, Hispanics are three times more likely, and among construction workers, they are twice as likely to suffer heat-related death. They also have higher occupational exposure to carbon monoxide.

Thompson, who also serves as the President of the National Association of Hispanic Nurses, went on to explain how lifestyles and sustenance are also at risk for certain ethnic groups due to climate change. For instance, Native Americans and Alaska Natives (NA/AN) rely on hunting and fishing, which are threatened by changes in climate. NA/AN populations also have poor access to potable drinking water and NA/AN children are more susceptible to hospitalizations from diarrhea due to this reason.

Thompson went on to emphasize that change would require empowerment, collaboration, and advocacy. Public policy must involve improving living conditions for low-income communities with improved climate resilience and a reduction in health disparities. This requires a coordinated strategy among healthcare, government, industry, education, research, and community-based organizations, she said. Entities must also ensure that information and education on climate change is linguistically and culturally accessible to communities of color, and that they account for historical trauma and marginalization. Economic stability must also be considered, including the costs involved with carbon reduction approaches and adoption of solar and other sustainable energy sources.

A lot can be done at the individual level to effect change. “We must volunteer with agencies that educate about climate change and advocate for systems, policies, and programs that address climate change," Thompson said. “I am a big proponent of 'If you don't like what you see in your community, then volunteer and make a difference.'"

Individuals can also help mitigate climate change impact by supporting climate-conscious candidates for office, increasing household energy efficiency, driving less, and volunteering with organizations that are involved in climate action, she said.

Thompson also had a message for healthcare professionals. “As a healthcare professional I have learned over time that healthcare professionals' power is in collective action in that we need to seek allies, we need to engage. As healthcare professionals we can also promote climate literacy among healthcare workers, providers, and administrators."

For healthcare providers, Thompson emphasized the importance of promoting climate literacy, providing culturally competent care, offering climate education to vulnerable populations, supporting patient access to the social determinants of health, and taking efforts to help their own organizations in carbon footprint reduction and emergency preparedness planning.

Thursday, April 15, 2021

CDC and FDA issue statement on Johnson and Johnson vaccine pause

This week, the FDA and CDC recommended a pause on the COVID-19 vaccine from Johnson & Johnson (J&J) following a rare but severe type of blood clot (cerebral venous sinus thrombosis) seen along with thrombocytopenia, reported in six women in the US. All afflicted women are between the ages of 18 and 48, and developed symptoms six to 13 days after vaccination. One woman died as a result of the complications.

The two agencies have released a joint statement on the pause, and the CDC's Advisory Committee on Immunization Practices (ACIP), will review the cases and data to assess their significance. The FDA will also review the cases and the ACIP analysis.

According to the statement, one of the primary concerns is that treatment of this particular type of blood clot is different from standard treatment that a patient may receive for blood clots, which is, typically, an anticoagulant drug called heparin. However, this particular case necessitates alternative treatments, as use of heparin may be dangerous.

More than 6.8 million people across the US have received the J&J vaccine. With six reported cases among nearly 7 million people, such adverse reactions are extremely rare; the pause reinforces the emphasis on COVID-19 vaccine safety.

There is little reason for alarm among patients who received the J&J vaccine. As director of the National Institute of Allergy and Infectious Diseases Dr. Anthony Fauci has said, the chances “are less than one in a million."

However, those who have received the J&J vaccine and experience severe headache, abdominal or leg pain, or shortness of breath within 3 weeks of receiving it, must contact their physician for evaluation and any treatment required. Healthcare providers should report any adverse reactions to the Vaccine Adverse Event Reporting System.

Some experts have questioned the administration's decision to pause the vaccine, with concerns that this may lead to vaccine hesitancy. However, federal officials asserted that the decision was made to inform the medical community about associated risks with vaccine safety in mind, as it was impossible to know if there were additional unreported cases of brain blood clots, which would result in even more people receiving the wrong diagnosis and treatment, causing more critical illnesses or death. Not surprisingly, the pause inspired a great deal of vaccine misinformation.

The AstraZeneca-Oxford vaccine, which is not yet approved for use in the US, has also been associated with rare cases of blood clots. Reports of the blood clots led to plummeting confidence in the vaccine's safety all across Europe last month.

Friday, April 9, 2021

High pollen counts can increase susceptibility to COVID-19 infection

As we enter the spring season in much of the U.S., flowers are in full bloom, trees are sporting leaves again, and the sun is shining through windows. But along with these wonderful aspects of the season, come pollen and allergies.

In addition to itchy eyes, runny noses, and other symptoms and effects of pollen, this year brings an additional concern. Research has shown that exposure to pollen can lower our innate immune response to respiratory viruses. Pollen interferes with proteins that are involved with antiviral responses in airway linings, diminishing antiviral immunity by reducing the body's immune response by interferon‐λ and pro‐inflammatory chemokines in airway epithelia. This leaves people more vulnerable to many respiratory pathogens, including the flu and SARS viruses.

Not surprisingly, a recent study shows that pollen can make people more vulnerable to infection by SARS-CoV-2, the virus that causes COVID-19. Researchers began by investigating if there was a link between COVID-19 infection rates and pollen concentrations. Other meteorologic factors, such as humidity and temperature, were also measured. Additionally, the researchers considered the effects of population density and lockdown measures to determine the impact of social contact on this interaction.

The study analyzed variability in COVID-19 infection rates in 130 different sites in 31 countries across five continents as pollen levels changed. The researchers found that on average, pollen explained 44% of the variability in infection rates, often concomitant with humidity and temperature. COVID-19 rates increased by around 4 percent, on average, for every 100 pollen grains per cubic meter of air.

Infection rates were seen to rise 4 days after high pollen counts were measured. This 4-day lag is explained by the presumed physiological process via which pollen affects the immune system – interference with the body's innate immune system. More importantly, results showed that the increase in case rates due to pollen was reduced by half in sites where lockdown measures were in place, indicating that reduced social contact did lower the effect of pollen on increasing COVID-19 infections.

It is important to note that the susceptibility to COVID-19 due to pollen is unrelated to allergic symptoms themselves and can be seen in people regardless of whether they exhibit allergy symptoms or not. In fact, even pollen that does not generally cause hay fever can increase the likelihood of SARS-CoV-2 infection.

There is really no way to avoid pollen during high counts in the spring. So what precautions can people take? Experts recommend that individuals who are at high risk for COVID-19 try to stay indoors as much as possible when pollen levels are high. Wearing particle filter masks while going outdoors during times of high airborne pollen concentrations can help filter out pollen particles and spores.

It is especially important to wear masks when exhibiting allergy symptoms since sneezing can increase an individual's likelihood of spreading COVID-19, should he or she have an infection. Allergy symptoms can be very similar to mild symptoms of COVID-19, so it is imperative to be careful and follow guidelines for social distancing. It is important for healthcare providers to ensure that their patients are aware of the risks of greater susceptibility to COVID-19 due to high pollen counts, so appropriate safety measures can be taken.

Thursday, March 25, 2021

Diversity, Equity, and Inclusion in Nursing

“Diversity is defined as individual attributes that extend beyond race, age, and gender, and also include, but are not limited to, characteristics such as national origin, immigrant status, language, color, disability, ethnicity, religion, sexual orientation, gender identity, socioeconomic status, veteran status, and family structures" [American Association of Colleges of Nursing (AACN), 2021]. Diversity highlights the vast differences among people while accentuating the similarities and intersectionality. How we are different; although we appear to be different, how are we alike, and what parts of diversity are hidden? “Inclusion is defined as a culture that encourages collaboration, flexibility, and fairness and leverages diversity so that all individuals can participate and contribute to their full potential" (AACN, 2021). How can we attain diversity of thoughts and actions? “Achieving health equity is when every person has the opportunity to reach their fullest health potential" [Centers for Disease Control (CDC), 2020]. How can we ensure all patients have access to the highest quality healthcare services? Diversity and inclusion must be present to attain health equity.

Health equity requires the delivery of culturally competent care that leads to ameliorating health disparities and inequities and improving outcomes. Culturally competent care is best delivered by healthcare providers who understand the significance of care individualization; are sensitive to the diverse cultural backgrounds of patients and their preferences; and assess and apply the social determinants of health, “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes" (CDC, 2021). Historical and current medical negligence and injustices experienced by underrepresented groups such as Black people have implications for the deterrence of seeking healthcare services. Thus, in some cases, patients tend to trust those who look like them. Access also serves as an impingement on the quality healthcare needs of those living in rural and underserved areas compounded by the inability to afford healthcare services.

Importance of diversity in the NP workforce

In the midst of the recommendations provided by the Institute of Medicine (IOM) Report, The Future of Nursing: Leading Change, Advancing Health, lay the critical need to increase diversity in the nursing workforce to improve access to quality, culturally competent, healthcare services, essentially leading to health equity. “NPs are recognized as expert healthcare providers who provide the highest quality of care" [American Association of Nurse Practitioners (AANP), 2021]. Maximizing the diversity of NPs while providing an inclusive environment to support the delivery of equitable care to all patients should be at the core of NP practice. “With more than 1.06 billion visits made to NPs each year" (AANP, 2021) and an increasingly diverse NP workforce, NPs have the ability to make a difference in diverse, rural, and underserved populations.

Strategies to increase diversity of NPs

The NP profession must continue to diversify until representation is adequate for the care of underrepresented groups (e.g., racial and ethnic minorities, socioeconomic disadvantaged backgrounds, men, etc.). Strategies for increasing the diversity of NPs begin with higher education institutions offering NP programs. “With projections pointing to minority populations becoming the majority, higher education institutions and prospective NPs must be educated to demonstrate a sensitivity to and understanding of a variety of cultures to provide high-quality care across settings" (AACN, 2020). The Health Resources and Services Administration (HRSA) Nursing Workforce Diversity (NWD) Grant provides an ideal model for increasing opportunities for individuals from disadvantaged backgrounds including racial and ethnic minorities using six evidence-based strategies for diversifying NPs in the workforce. These strategies are aimed at efforts to recruit, retain, and graduate students from underrepresented groups living in rural and underserved communities. Below are the HRSA (2021) strategies along with some examples:

Holistic Review

Creating institutional support for diversifying the admissions process and metrics to ensure the admittance of diverse, underrepresented students (e.g., racial and ethnic minority students) into institutions of higher education.

Student Support Services

Academic support (e.g., tutoring and writing support)
Peer support
Affinity groups

Mentoring

Effective mentoring programs to support students' programmatic and professional goals

Student Financial Support for the Social Determinants of Education

Scholarships
Support for scholarly activities

Recruitment and Retention of Faculty from Underrepresented Groups

“Increasing racial and ethnic diversity among faculty in NP programs will enrich and strengthen education, practice, service, scholarship, and research" [National Organization of Nurse Practitioner Faculties (NONPF), 2018].

Collaborative Partnerships

Marketing and Public Relations (representing diversity, equity, and inclusion [DEI])
Professional Organizations (diverse organizations that support underrepresented groups such as the National Black Nurses Association, National Association of Hispanic Nurses, and National Alaska Native American Indian Nurses Association)
Creating pipeline programs with racial and ethnic minority universities such as historically black colleges and universities (HBCUs)

Other strategies include:

Institutional Support

Acknowledgement (Mission, Vision, Values, Strategic Goals)
Policy and Practice Changes (e.g., mitigating bias)
Accountability (e.g., employee evaluations)

Education

Providing community-wide education on DEI and racism

Curriculum

Integrating the concepts of DEI and racism throughout the curriculum with a focus on health equity

Developing, implementing, and evaluating the outcomes of these evidenced-based strategies have proven effective in increasing the diversity of NPs in the workforce.

Decreasing racism within the healthcare system
Since the Civil Rights Movement of the 1960s, changes have occurred to improve the treatment of Black people; however, the underpinnings of systemic and structural racism are alive and well in the U.S. The year, 2020, bestowed upon us an undeniable reality check on the national impact of systemic and structural racism in the healthcare delivery system through the inequitable outcomes of the COVID-19 pandemic. As of March 17, 2021, the CDC reports “533,057 deaths in the U.S., 289,119 of which were reported by race. Of those 289,119 deaths in which the race was known, 14% of the victims were identified as Black, non-Hispanic." Although underrepresented in the U.S., Black people disproportionately lead the death toll rates as they suffer from existing socioeconomic hardships and the adversities brought on by the pandemic.

According to the U.S. Census Data (2018) and National Council of State Boards of Nursing (NCSBN) (2013) as cited in National League of Nursing (NLN) (2016) approximately 80% of registered nurses, NPs, and nurse-midwives in the U.S. are white, adequately addressing the race-related cultural competency of delivering healthcare services for White individuals, while people of color (e.g., Black and Native populations) are without adequate representation and access to quality healthcare. The health of people of color continues to deteriorate under the sheer auspices of care provided by a predominately white healthcare profession as seen with the COVID-19 pandemic, pregnancy outcomes, and the host of chronic illnesses and associated complications impacting their health and wellbeing. “Predictions reveal that by 2045, over half of the U.S. population will consist of minority populations" (U.S. Census Bureau, 2018). Increasing the diversity of the NP workforce is of utmost importance to reduce health disparities and inequities and improve outcomes to save lives in diverse, rural, and underserved communities. Ensuring all patients receive equitable healthcare should be at the core of nursing practice.

Geraldine Q.Young, DNP, APRN, FNPBC, CDE, FAANP is a National Organization of Nurse Practitioner Faculties (NONPF) Leadership Fellow, a Board Member at Large at NONPF, Chief Diversity and Inclusion Officer at Frontier Nursing University, Versailles, Ky., and Diverse Magazine Leading Woman in Higher Education.

References

American Association of Colleges of Nursing. (2021). Diversity, inclusion, and

sustainability in nursing education lectureship award. Retrieved from https://www.aacnnursing.org/Membership/Volunteer-Engagement/AACN-Awards/Diversity

American Association of Nurse Practitioners (2021). What’s a nurse practitioner (NP)?

Retrieved from https://www.aanp.org/about/all-about-nps/whats-a-nurse-practitioner

Centers for Disease Control and Prevention (CDC). (2020). National Center for Chronic Disease

Prevention and Health Promotion (NCCDPHP): Health equity. Retrieved from https://www.cdc.gov/chronicdisease/healthequity/index.htm

CDC. (2021). COVID data tracker. Retrieved March 17, 2021 from

https://covid.cdc.gov/covid-data-tracker/#pop-factors_7daynewcases

CDC. (2021). Social determinants of health: Know what affects health. Retrieved from

https://www.cdc.gov/socialdeterminants/index.htm

Health Resources & Services Administration (HRSA). Nursing Workforce Diversity (NWD) Program. Retrieved March 24, 2021 from https://www.hrsa.gov/grants/find-funding/hrsa-21-020

National League of Nursing (NLN). (2016). Achieving diversity and meaningful

inclusion in nursing education: A living document from the National League for

Nursing. Retrieved from http://www.nln.org/docs/default-source/about/vision-statement-achieving-diversity.pdf?sfvrsn=2

National Organization of Nurse Practitioner Faculties (NONPF). (2018). NONPF calls for

greater racial and ethnic diversity in nurse practitioner education. Retrieved from https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/docs/20180807_diversity_statement.pdf

U. S. Census Data. (2018). Data USA: Nurse practitioners and nurse midwives. Retrieved from

https://datausa.io/profile/soc/nurse-practitioners-nurse-midwives#:~:text=The%20number%20of%20people%20employed,to%20198%2C458%20people%20in%202018

U. S. Census Data. (2018). The US will become ‘minority white’ in 2045, census projects:

Youthful minorities are the engine of future growth. Retrieved from https://www.brookings.edu/blog/the-avenue/2018/03/14/the-us-will-become-minority-white-in-2045-census-projects/