Nurse leaders can integrate holistic care by first checking whether their organization's culture is aware of what consumers want.
Jesus Cepero, PhD, RN, NEA-BC, witnessed a profound example of holistic patient and family care when a priest was called in to give comfort to a dying hospital patient and the patient's family.
"He created an environment in that room where everyone felt almost comfortable with the situation and it moved our thinking from trying to save a life to meeting the needs of the patient and their family," Cepero says. "It's something I'll never forget."
Cepero, who recently joined Stanford Children's Health in the San Francisco Bay Area, as senior vice president and chief nursing officer where he leads more than 1,900 nurses, is an advocate of holistic patient and family care encompassing mind, body, and soul.
"I've always felt that mind, body, and soul are three things that I've paid attention to myself and, to me, it's just part of my life and my own spiritual background," he says. "So, when I'm thinking about programs or services or the care that patients and families need, I think in those terms."
With more than 20 years of healthcare leadership experience, Cepero has held nursing and operational leadership roles across multiple specialties, including adult and pediatric emergency departments, critical care, women and infants' services, forensics, and surgical services, and served for the past eight years as a chief nursing officer for large healthcare systems.
Advanced science, new medications, and cutting-edge processes have made modern healthcare more efficient, but they are not the only aspects of healing, he says.
"We've learned great things and patients have gotten better, but in that task-oriented mindset you forget about the patient's spiritual needs or the patient's wellness needs," he says. "It's important that we have a good social service or care management approach to making sure that we're meeting all the patient's needs, as well as highly, technically experienced, proficient health providers to be able to meet the needs of the person as far as wellness and cure."
While with Meritus Health in Maryland from 2012 to 2017, Cepero deployed behavioral health screeners to implement depression screening, put in place a survivorship program at the cancer center, and redesigned the pastoral care residency program.
East meets West
Holistic healing is nothing new. Holistic healing has been identified in Chinese literature reaching back 5,000 years and Eastern treatment—therapeutic touch, acupuncture, aromatherapy, medication—has now become rooted in everyday Western healthcare to help patients deal with the stress of their illness or disease, Cepero says.
"Florence Nightingale, about 120 years ago, was talking about mindfulness and spirituality in nursing practice when delivering care to patients, so it's not new," he says.
But even with Florence Nightingale's insight, Western healthcare tended to focus primarily on the illness or injury, up until the last few decades, he says.
"In the last 50 to 75 years we've changed a lot, from trying to treat the injury or the illness, to looking at a person as a whole and trying to meet those needs," he says, "because you could cure somebody but miss the things that were important for the person or the family, which was, how are they treated for their spiritual needs? How are they treated for their mindfulness? How are they able to adapt to the new disease entity or injury that they're experiencing?"
The consumer has been the one to push holistic healthcare forward, he says.
"It's been more of a demand from the patient side, where patients want to go to be cured and healed, but they also want to be treated well," he says. "And they want all of their needs met."
Barriers to holistic care
One of the most difficult obstacles to holistic care is a language barrier, Cepero says.
"Hospitals are investing significant dollars to be able to have translators available around the clock so that you can understand each other, because one of the principles of holistic care is listening to the patient or the family to be able to meet their needs … and how do you do that if you're not able to communicate with them?" he says.
A language barrier doesn't only apply to different cultures. "A lot of time and attention has gone into communication for the English-speaking patients and families, because you want to assess how they want to be communicated with," he says. "Some people like verbal communication, some people want to see it in writing, and some people actually like video so they can have a clear understanding of their illness or injury."
A patient's socioeconomic situation may also get in the way of being treated holistically, Cepero says. For example, a patient might choose to have his or her illness or injury treated with acupuncture or massage, but insurance doesn't cover the procedure and the patient can't afford to pay for it themselves.
Integrating holistic health into a hospital
CNOs interested in introducing or expanding holistic care in their health system should start with three steps, Cepero says.
"First of all, I would assess the organization's culture and see if they are aware of the holistic approaches that our patients and our consumers are demanding," he says. "Second, I would ask them to consider looking at the resources that they're providing to their patients—their care demands—so that they can ensure that nurses do have the time to be able to manage the holistic approaches to meet those patient demands."
"Third, I like our system where we have focus groups of patients and families and assess from the patient and families' perspective, or even the community's perspective, as to how they want their healthcare services to be delivered," he says.
Integrating holistic health can be done even during the COVID-19 pandemic because nurses can make it happen, because no matter how time-strapped they are, nurses still find time to stop and meet the patients' needs, Cepero says.
"You have heard many stories where unfortunate COVID patients are dying and they can't have their families present, but the nurses stopped and made the connection on their phone or iPad to the family so that person in their time of passing was not there by themselves," he said. "I'm proud of our profession that no matter how taxed our nurses are … we still slow down in most cases to treat the patient's holistic needs and to ensure that they're getting their needs met, even during times of crisis."
COVID-19 also has caused children, especially in low-income families, to miss out on healthcare needs, report says.
Fearing exposure to COVID-19, combined with limited services caused by the pandemic, resulted in more than one-third of adults in the United States (36%) to delay or go without needed medical care, a new report says.
Nearly 29% of parents delayed or went without care for their children under age 19 for the same reasons.
Going without needed treatment had consequences, as one-third of the adults (32.6%) who reported delaying or forgoing care said one or more of their health conditions worsened as a result, or their ability to work or perform other daily activities was limited.
Adults with one or more chronic health conditions reported delaying or forgoing care at a rate of nearly 41%, which is cause for concern, particularly for people whose health can deteriorate rapidly without careful monitoring and treatment. Mortality data suggest the pandemic has caused a surge in excess deaths from conditions such as diabetes, dementia, hypertension, heart disease, and stroke, the report says.
Black adults were more likely than white or Hispanic/Latino adults to report delaying or forgoing care (39.7% versus 34.3% and 35.5%, respectively) and more likely to report delaying or forgoing multiple types of care (28.5% versus 21.1% and 22.3%, respectively), according to the analyses.
Other findings included:
More than half of adults with both a physical and mental health condition (56.3%) reported delaying or skipping care.
Dental care was the most common type of care adults delayed or did not receive (25.3%).
One in five respondents (20.6%) delayed or went without a visit to a general doctor or specialist.
Slightly more than 15% delayed or went without some form of preventive care.
"Prolonged gaps in needed medical care lead to adverse health outcomes and could create long-term economic challenges as we navigate out of the pandemic," said Mona Shah, senior program officer at the Robert Wood Johnson Foundation.
Among parents with children under 19, researchers found that 28.8% reported their children had delayed or missed one or more types of healthcare due to the pandemic and 15.6% reported delaying or forgoing multiple types of care for their children, especially parents with lower incomes (19.6% versus 11.4% of parents with higher incomes).
"The pandemic has caused children, especially those in low-income families, to miss out on a range of healthcare needs," said Dulce Gonzalez, research analyst at the Urban Institute. "These gaps in care could harm children’s health, development, and well-being—but targeted efforts to make up for missed care could help avoid exacerbating socioeconomic inequities."
The solution to unmet healthcare needs requires effectively calming fears about exposure to the coronavirus, the report advises.
"Patients must be reassured that providers' safety precautions follow public health guidelines, and that these precautions effectively prevent transmission in offices, clinics, and hospitals," it says. "More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed."
HCA Healthcare's Chief Nurse Executive Jane Englebright shares how the hospital system has helped her nurses cope with the pandemic.
While COVID-19 is taking an emotional toll on nursing staffs, indications are that Gen Z nurses—those between the age of 18 and 22—generally are having a much tougher time.
Generally, the simple fact of their age, with its lack of life experiences and adversity, and therefore resilience, is a major factor, according to the study, Keeping an Eye on Generation Z Nurses.
"Most Generation Z nurses have less experience with adversity," the study states. "It is difficult for them to put the COVID-19 experience into any context."
Data from a recent survey, Nurse Wellbeing At Risk, indicated that Gen Z nurses were the most likely (57.3%) to report that COVID-19 had negatively impacted their overall well-being; they were the least likely (23.5%) to report managing work-related stress and anxiety; and only 15.4% felt comfortable discussing their well-being with their manager—a sharp difference from their baby boomer counterparts (59.6%).
Jane D. Englebright, PhD, RN CENP, FAAN, is senior vice president and chief nursing executive for HCA Healthcare, which employs about 98,000 nurses, most of whom, she says, are millennials and Gen Z.
HealthLeaders recently spoke with Englebright about how HCA has helped the hospital system's nurses—particularly its youngest nurses—navigate the pandemic.
The following is a transcript of the conversation, lightly edited for clarity and brevity.
Jane Englebright: What it helped us do was to prioritize the things that were important to this growing segment of our nursing population. What came out of it was their need for flexibility, how important relationships were to them, having a positive work environment, and the importance of teamwork and how they want to feel part of a team. We got a lot of insight into training that we ended up using a lot this year in terms of how they prefer to receive training information. And then there's the whole idea that they needed a way to have a voice. All of those things we sort of knew going in, but it gave us a little more insight, and we turned around and tried to apply that to almost everything that we were dealing with [with COVID-19].
HL: How did the study help HCA prepare to manage through a pandemic?
Englebright: It was important and continues to be important as we manage a continuous flow of up-to-date, accurate information. Do you remember in the beginning of the pandemic, that we were still having conflicting guidelines coming out? As everything evolved and continued to change, and as we learned more, we had to get education to the front line fast. We had already been working on our centers for clinical advancement and a new education model and moving a lot of our education from the PowerPoint with voiceover to little mini videos, so we ramped that up in a significant way.
The other thing we came up with was how to put reference materials at their fingertips that would never be out of date. We made these posters that can be hung up in the wall of the nurses' station, or even in a patient room, that had a QR code on it that links you to the master document and they could always just scan that code and read the latest. We could maintain everything in a central database that had all the latest information in it and not worry about a lot of outdated information still being out there in the unit.
HL: Even more seasoned nurses are struggling with the effects of the pandemic. How have your younger nurses grappled with it?
Englebright: Every age group has had the full spectrum of responses. There are different life stressors, but they're all struggling with the disruption in their personal lives, as well as the disruption in their work life. This last month, I've spent quite a bit of time working in the TriStar vaccination clinic and you see the nurses coming through it and you can see the variation of how they're coping and their response. Some are coming in playing their walking music and dancing it out, happy that we're to the vaccine stage. Others come in in tears because we're in the vaccine stage. And I think that's what we've seen all along. At every stage of this, we've had the full range of responses.
HL: How did HCA help the nurses cope as the pandemic worsened?
Englebright: We put in place a Nurse Care Program [a free, confidential program partnered with a company offering licensed psychologists, counselors, and therapists]. We had been piloting it in 2019 and when we got into the situation in March, we ramped it up and rolled it out to the rest of the company in a six-week period and it's been widely accepted. About 90% of the calls that come through are the Gen Z and millennial nurses. Of almost 26,000 calls, about 20,000 of them are related to COVID, so the younger nurses are calling in larger numbers than the more seasoned nurses.
HL: How have you measured the outcomes of some of these actions that you've taken for your nurses?
Englebright: A couple of ways. We've done some poll surveys asking, "What's important to you, and what else do you need?" What we got back from them was that they had two things that were their key needs. One was frequent communication. That was the No. 1 way they felt that they were being supported. And then the other thing they need is to feel a sense of being safe at work and an understanding of all the work-related stress. So I think we've done that.
Our universal protection protocol that we put in place about being safe in the work environment seems to have worked and people seem to have confidence in it. And then with work-related stress, how we came at that was, first, the Nurse Care Program. The second was we leaned heavily on our behavioral health experts throughout the organization and had them assemble resources on stress management [on our intranet]. While I was making rounds at one of our hospitals, I saw some of the nurses gathered around a computer together and I asked, "What are you guys doing?" and they said, "We're watching the mindfulness video. We do it every day at this time."
HL: The Nurse Well-being At Risk survey says that only 15.4% of Gen Z nurses felt comfortable discussing their well-being with their manager. Given that, how does a CNO or other nurse managers successfully "take the temperature" of how their youngest nurses are doing?
Englebright: Besides the couple of things I mentioned and the pulse surveys that we do periodically, we also have a practice of employee rounding, where managers spend time with each employee on a regular basis, where they just talk about them: "How are you doing? What are your career aspirations? Where do you want to go next? How can I help you develop?"
Then we've launched an app that our nurses designed, that we call HCA Inspire. This app has social networking features and where [nurses] can recognize each other. [It] also has an ability to find a mentor; [nurses] can go in and match up with a mentor to talk.
Staffing levels and patient safety are at the center of the nurses' demands.
Nurses at St. Vincent Hospital, in Worcester, Massachusetts, overwhelmingly voted Wednesday night to authorize their negotiating committee to call for a strike should bargaining talks with Dallas-based Tenet Healthcare break down.
The 800 nurses say that Tenet refuses their demand, after spending more than a year in negotiations, to increase staffing levels at St. Vincent hospital to better protect patients during the ongoing COVID-19 crisis and beyond, according to a Massachusetts Nurses Association (MNA) news release.
The parties resumed talks with a federal mediator Thursday, in which nothing was resolved.
"Management chose to respond through the federal mediator that they had no interest in dealing with staffing in any way and then issued an ultimatum: we must accept their last best and final offer prior to Feb. 18th," according to a statement released by MNA. "In response we sent a message to management that we remain committed to engaging in a good faith negotiation on all issues, and it must include staffing. Through the mediator, they stated they will not engage on staffing."
"Be assured we do not respond to ultimatums and threats and we will do whatever it takes to ensure we can provide the care our patients and our community deserves," the statement continued, "including planning for the strike the nurses authorized should that be needed."
Should the nurses' union strike, St. Vincent will remain fully operational, Tenet Healthcare said in a statement.
"The MNA is trying to alter staffing guidelines and has unsuccessfully tried to put forth staffing ratios in the legislature for more than a decade," the statement read. "Our current collective bargaining agreement already includes staffing guidelines which were negotiated with the MNA and that are better than most other hospitals."
Patient safety is at the heart of the matter, said Marlena Pellegrino, RN, a frontline nurse at the hospital and co-chair of the nurses local bargaining unit with the MNA.
"As nurses, we are legally and morally obligated to advocate for our patients to ensure they are safe and receive the care they deserve," she said. "While our goal is to avert a strike, should Tenet maintain its obstinance at the table, we will be compelled to take that step because our patients' lives are on the line."
Since the onset of the pandemic, nurses have filed more than 500 official reports of conditions that they say have jeopardized the safety of patients, cast a no confidence vote in their CEO, and watched more than 100 nurses leave the facility, according to the press release.
The nurses, who previously called out Tenet for "corporate greed," heightened that charge Tuesday after Tenet released the company's latest earnings report, posting a net income from continuing operations of $414 million in Q4 2020, improving upon a net loss of $3 million in Q4 2019.
The day before the vote, St. Vincent's CEO Carolyn Jackson said any thought of a work stoppage was "irresponsible" considering the circumstances, according to MassLive.
"We certainly are hopeful that we can reach an amicable resolution to the contract, and that there is no strike," Jackson told the news organization. "I feel that it's irresponsible to even talk about a strike during a global pandemic and we feel we have an excellent offer on the table."
In an open letter, the AHA stated the high rate hikes "appear to be naked attempts to exploit the pandemic."
COVID-19 has made nurses more in demand than ever, forcing some hospitals to pay traveling nurses as much as $12,000 weekly and prompting the American Hospital Association (AHA) to ask the Federal Trade Commission (FTC) to investigate reports of anticompetitive pricing by nurse-staffing agencies.
"The AHA has received reports from hospitals across the nation that nurse-staffing agencies, which supply desperately needed staff to care for patients suffering from the COVID-19 virus and other conditions that require hospitalization, are engaged in anticompetitive pricing," Melinda R. Hatton, AHA general counsel, said in a recent letter to Rebecca Slaughter, acting chairwoman of the FTC.
Hospitals have used travel nurses for decades to fill short-term vacancies, but as beds are filled with COVID-19 patients, combined with staffing shortages from ill or quarantined staff, interim nurses are in extraordinarily high demand and competition is intense.
Some Houston nurses were leaving their hospital jobs to earn as much as $12,000 weekly as traveling nurses, the Houston Chronicle reported last month. One nurse-staffing site is currently offering jobs in the ICU, ER, and stepdown units with weekly pay ranging from $5,500 to $10,010.
"Such outrageous rate hikes appear to be naked attempts to exploit the pandemic by charging supracompetitive prices to desperate hospitals," the AHA letter stated. "While the nurse staffing agency industry too often blames hospitals for driving up the rates, the fact is that hospitals are in dire need of nursing staff to care for their patients and have little choice but to pay the rates demanded and refrain from complaining publicly for fear of being cut off from the supply of travel nurses by staffing agencies that set the prices."
High rate hikes shift the finite supply of nurses toward more affluent areas, often leaving rural and urban public hospitals short-staffed.
The AHA letter called for the FTC to use its governmental authority to investigate the price hikes.
"The impacts on hospital costs and patient care from these practices are manifold," the letter stated. "Therefore, we request the FTC use its authority to protect consumers from anticompetitive and unfair practices to investigate this activity and take appropriate action to protect hospitals and the patients whom they treat."
Nurse leaders who are seeking a job change 'will find opportunities,' says one nurse recruiter.
Though the COVID-19 pandemic has created high unemployment numbers and otherwise stalled countless careers, Chief Nursing Officers (CNO) will find opportunities in the market right now, says Rachel Polhemus, a senior partner at WittKieffer, a global executive search firm headquartered in Chicago.
Senior-level opportunities are available despite an ongoing registered nurse (RN) shortage that, according to the United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit published in the May/June 2018 issue of the American Journal of Medical Quality, is projected to spread across the country between 2016 and 2030.
Retirement or opportunities to take a job closer to home have created most of the openings—not because CNOS are leaving the industry, Polhemus says.
"They are not leaving their posts," she says. "They're trying to be there for nursing because they know how much they're needed."
CNOs who are looking for a change or Associate CNOs (ACNO) or nurse managers looking to advance will find opportunities—if they're the right fit, she says.
"This is the right time to stick your toe in the water and test your competencies and see how they measure in the market," she says.
But be mindful of the place and position you're considering, she advises. "Don't just jump at an opportunity because it's open," she says. "Find out as much about the organization as possible."
"Make sure it's a culture fit and the values there align with you as a person," she says. "Just because it's a bigger job doesn't mean it's the right job for you."
Must-have skills and knowledge
CNOs seeking a change or nurse managers looking to move up into a CNO role need good management skills to get noticed, Polhemus says.
"They need to be someone who knows how to engage their nursing workforce and who has been able to creatively look at recruitment and ways to recruit and retain staff," she says. "The ability to recruit and retain is tremendous right now."
The average national turnover rate for bedside RNs was 16.8% in 2017, according to the recruitment firm NSI Nursing Solutions, Inc. The 10-year RN Work Project study found 17% of newly licensed RNs leave their first nursing job within the first year, 33% leave within two years, and 60% leave within eight years.
"The clear need in organizations in having a strong leader to help drive recruitment and retention strategies is critical," she says.
Besides the nursing staff, an effective CNO must also possess the ability to build relationships with other medical staff, administration, and various teams throughout a hospital or health system, she says.
Knowledge and skills in finances and business are required of nearly any CNO, Polhemus says.
"You would hope along the path, someone would have some P&L and financial acumen and the ability to develop a budget," she says. "It's critical in managing resources and recruitment needs because the cost of recruiting a nurse is expensive and if you lose them two years later, you're losing money."
Indeed, the cost of turnover for a bedside RN ranges from $33,300 to $56,000 per nurse—an average of $44,400—which can result in the average hospital losing $3.6 million–$6.1 million annually, according to the 2020 National Healthcare Retention & RN Staffing Report.
Many ACNOs and other nurse managers on the rise have graduated from an MBA or other master's program, while nursing students have financial classes connected to their programs.
"But also, many times someone on the rise gets mentored by a CNO," she says. "Getting someone to guide you is critical."
CNO who meets needs, boosts staff morale is especially important
Getting to know an unfamiliar staff during a pandemic is a unique challenge to CNOs as they find their way in a new organization, Polhemus says.
"They're learning the teams in a different way, in a socially distanced way, through Zoom," she says. "Some are in person, but it's not in the same orientation as it's always been done before."
Figuring out how to manage and provide care during COVID-19 while developing a vision around other programmatic needs is a pandemic-particular challenge for CNOs, she says.
"They have to develop and maintain the COVID units but they have to figure out how to grow other units," she says, "whether they're recruiting for oncology or cardiovascular or L&D nurses."
Understanding staff morale—knowing where they are and how to meet their needs—is also critical for a CNO new to an organization, she says.
"Morale issues are a big part of [the pandemic]," Polhemus says, "and they have to build the relationships so [nurses] trust the CNO and feel like they can open up to them."
Good candidates not only must know how to boost staff morale, but they must also know when to realize that one of their nurses is approaching burnout and encourage them to take time off, she says.
"They want a leader who can identify mental health needs of their workforce in ways they could not two years ago," she says. "The amount of trauma these nurses have been exposed to through COVID is far different than any trauma in their career."
Mindful Recruiting
The pandemic and its effects have changed the way Polhemus has approached recruiting CNOs.
"We've been very careful," she says. "We've been thoughtful about not reaching out to CNOs in certain locations and waiting for things to even out and die down. As we approach any recruitment, we're recognizing that everybody is dealing with a very challenging time. We're recognizing their leadership and what they're doing for their organization right now, rather than just jumping in and recruiting."
One strategy WittKieffer is using in filling a specific position is to search for CNOs who may have been born or educated in that region and may want to return there, Polhemus says.
"There's been an uptick of all executive-level positions for leaders to go back home to be closer to family to take some stress away," she says.
Hospitals also are making changes in recruiting, with some choosing to reach slightly down the chain of command to plan for their future, Polhemus notes.
"Some organizations, and I commend them, are recruiting an ACNO and planning for succession, knowing the CNO will retire in the next year," she says. "The talent market is competitive right now and some organizations are being proactive for the future to make sure they have a succession plan."
Diversity and inclusion, which are critical to achieving health equity and reducing disparities in healthcare, are being embraced by health systems who are looking for CNOs, Polhemus says.
"There is a real focus around diversity right now," she says. "Organizations want leadership teams to look like the communities they serve. There is a real need for leadership across all ethnic, racial, religious, and all groups … which is excellent because it helps bring forth talent that we have not seen before."
The document is first in a series of Joint Commission alerts that address healthcare workers' concerns and provide guidance on how to respond to crisis, preparing them for the often-overwhelming circumstances of caring for patients during a pandemic.
One Iowa nurse quoted in the publication explained in stark terms how the continuing onslaught of COVID-19 is pushing nurses and other frontline healthcare workers beyond physical exhaustion and inflicting emotional damage on those who care for patients.
"To be a nurse, you really have to care about people," the hospital nurse said. But when an ICU is packed with COVID-19 patients, many of whom are likely to die, "to protect yourself, you just shut down. You get to the point when you realize that you've become a machine. There's only so many bags you can zip."
This nurse's experience is among more than 2,000 COVID-19 related comments from healthcare workers, their loved ones, and other community members to OQPS.
Comments made to OQPS reflected some of the most common concerns healthcare workers are experiencing:
Fear of the unknown
This fear results, in part, from unclear, confusing, or contradictory guidance from various leading sources about what precautions to take to contain the spread of COVID-19. Shortages of personal protective equipment (PPE), certain medications, and critical medical devices made this lack of direction even more complex and troublesome for workers to manage, said Raji Thomas, director of The Joint Commission's OQPS.
Fear of getting sick
Fear of getting sick from the COVID-19 virus was high within the healthcare workforce, especially among workers more likely to experience serious complications from the virus due to their age, preexisting conditions, or other factors. Such fears were amplified by PPE shortages.
Fear of bringing the virus home
Fear of infecting family members, particularly older adults and children, reflected a significant percentage of the complaints received from workers. They shared stories about living in hotels, changing out of their clothes in the garage before entering the house, and showering as soon as they came home. Some workers opted to leave healthcare altogether during the pandemic due to this fear.
To address these concerns, the alert encourages healthcare organizations to:
Foster open and transparent communication to build trust, reduce fears, build morale, and sustain an effective workforce.
Remove barriers to healthcare workers seeking mental health services and develop systems that support institutional, as well as individual, resilience.
Provide clinicians and others with opportunities to collaborate, lead, and innovate.
"The COVID-19 pandemic has lasted for much longer than many of us anticipated, and healthcare workers are feeling the physical and emotional strain of longer hours, higher patient-provider ratios, and rising patient death tolls," said Ana Pujols McKee, MD, executive vice president and chief medical officer, chief diversity and inclusion officer at The Joint Commission. "While vaccinations offer an opportunity to end the pandemic, healthcare organizations have a responsibility to support their workers' well-being for the long term."
For more resources, The Joint Commission has compiled the Coronavirus Resources portal, which contains links to recommendations for staff health and well-being, webinar recordings, and information on The Joint Commission's advocacy efforts for healthcare workers during the pandemic.
The CDPH also said it will not approve new expedited staffing waivers.
The announcement was welcome news to more than 100,000 RN members of the California Nurses Association, many of whom had actively protested—some even going on strike—against the waivers.
"This is an incredible victory for patients and nurses, because we know that safe staffing saves lives," said Zenei Triunfo-Cortez, RN, and a president of the California Nurses Association and its national organization, National Nurses United. "It was our collective action as a union that defeated the money and lobbying power of the hospital industry, which we know is focused on the bottom line, not safe patient care."
Hospital employers began applying with CDPH last summer for waivers of California’s safe staffing standards, which specify for various hospital units the maximum number of patients that can be assigned to one nurse—with adjustments made for severity of patient illness.
COVID-19 already had severely strained staffing because care is more complicated, patients are the sickest they've seen, and many staff were unable to work because they themselves had contracted the virus.
In December, CDPH allowed hospitals to automatically obtain blanket "expedited waivers" of safe staffing ratios for critical departments such as the ICU and emergency room, among others.
Nurses have been protesting all waivers of safe staffing standards, arguing that patients need more, not less, care during the pandemic and have staged direct actions inside and outside their hospitals in defense of safe staffing standards, including a mass mobilization most recently on January 27.
California is theonly state that stipulates by law a required minimum nurse-to-patient ratio, which occurred after more than 10 years of lobbying and activism. The patient-ratio bill passed the state legislature in 1999, but didn't go into effect until January 2004 followed by several more years of overcoming multiple court challenges, including one from then-Gov. Arnold Schwarzenegger, according to Kaiser Health News.
CDPH's announcement noted that all existing approved staffing waivers will expire February 8, unless CDPH determines on an individual basis that there is an unprecedented circumstance. Otherwise, hospitals must maintain efforts to meet required staffing levels at all times.
If there is any indication that a hospital has not maintained efforts to increase staffing, CDPH will investigate, the announcement said. Additionally, CDPH may do unannounced audits to assess these efforts.
"This win reinforces what we have learned over the decades in defending safe staffing standards against multiple attacks: Fighting back together works," said Triunfo-Cortez. "But we must continue to stay united and vigilant in protecting and enforcing the safe staffing standards we need to provide the kind of nursing care we know our patients deserve. Because we know this won't be the last time the industry tries to get rid of ratios."
Pneumonia and the flu kill tens of thousands of Americans each year, according to the U.S. Centers for Disease Control and Prevention, but new research from the University of Georgia (UGA) shows that state laws promoting flu vaccinations for hospital workers can substantially reduce the number of influenza-related deaths.
The 23-year study looked at the mortality rate from influenza and pneumonia during peak flu season—from December through March of each year—comparing changes in mortality in the 13 states and Washington, D.C., that had enacted laws requiring flu vaccines for identified categories of hospital workers to the changes in mortality in states without such laws.
All states that passed laws require the flu vaccines to be offered to hospital employees. Eleven states mandate that workers be vaccinated or require documentation of refusal, with three requiring unvaccinated employees to wear surgical masks during flu season.
Though the findings align with previous research suggesting that hospital workers may serve as vectors of disease transmission within their hospitals and even in their communities, vaccination rates remain low, particularly in nursing staff.
One study found three recurring main themes about why nurses decline the influenza vaccine:
Concern about side effects and desire to maintain a "strong and healthy body"
Protecting their "decisional autonomy"
Perception of health authorities, pharmaceutical companies, and scientists as "untrustworthy"
In some cases, healthcare workers refuse to get vaccinated because flu shots vary in efficacy each year due to the limitation of vaccine developers only being able to include several strains of the virus in a given shot.
However, the American Academy of Nursing strongly recommends nurses protect both themselves and their patients by adhering to the recommended vaccine schedule for health professionals.
"To optimize the health and well-being of patients, their families, and the community, nurses must be fully vaccinated," according to an Academy position statement. "When nurses work directly with patients or handle fluids, they are more likely to get—and spread—infectious diseases."
States that mandated hospital workers receive flu shots saw the biggest reduction in mortality from flu and pneumonia. On average, the adoption of a law promoting vaccination reduced mortality by about two deaths per 100,000 persons, with the reductions primarily occurring among older adult populations.
"The elderly are extremely vulnerable to influenza and are also generally less responsive to the vaccine," said Emily Lawler, corresponding author of the study and an assistant professor in UGA’s School of Public and International Affairs. "This study suggests that vaccinating hospital workers against influenza reduces influenza disease transmission and helps protect this vulnerable population."
Vaccinating hospital workers would protect all populations, as well, she said.
"Stricter policies result in higher vaccination rates among healthcare workers," Lawler said. "Our results are consistent with the idea that these stronger laws result in a larger reduction in influenza-related mortality."
80% of the health system's employees are getting on board to accept the COVID-19 vaccine.
As COVID-19 vaccinations expand beyond essential workers, 80% of CommonSpirit Health's 150,000 healthcare workers have been vaccinated, are scheduled to be vaccinated, or say that they are "very likely" to get vaccinated, according to a CommonSpirit Health survey conducted by Press Ganey Associates January 11–12, 2021, to 20,000 randomly selected CommonSpirit Health employees.
The company's vaccination rates are a stark contrast to reports of frontline workers opting out of vaccinations or expressing vaccine hesitance.
Roughly 20% to 40% of Los Angeles County's frontline workers who were offered the vaccine refused it, said county public health officials, while some health systems are seeing as much as 80% of the staff holding back, according to the Associated Press.
About 29% of U.S. frontline workers are refusing the vaccine for the same reasons as a mistrustful public: worries about possible side effects, concerns that the vaccine is too new, distrust of the vaccines' safety and effectiveness, and concerns over the role of politics in the development process, a Kaiser Family Foundation study reported.
But CommonSpirit Health, with 139 hospitals and more than 1,000 care sites in 21 states across the country, has helped encourage employees to get vaccinated through an education and awareness program focused on debunking COVID-19 vaccine myths through employee town halls and social media posts featuring clinicians.
"As one of America's largest health systems, we hope that the positive action of our employees is a bellwether for the entire healthcare industry," said CommonSpirit Health Chief Nursing Officer Kathleen Sanford, DBA, RN. "It's important to understand, it takes time to build this vaccine confidence, and we see this as an extremely positive upward trend."
The top two reasons employees chose to get vaccinated, according to CommonSpirit's survey, were "desire to protect my family" (97%) and "reduce the chance of me infecting others" (97%). These were followed by "reduce chances of me getting infected" (93%) and "if enough people can get vaccinated, we can get back to normal" (93%). Respondents also selected "because I work in healthcare, I need to be a role model" (79%).
CommonSpirit employees are role modeling for their respective communities by getting vaccinated themselves—69% of black respondents and 77% of Hispanic respondents have either been vaccinated, are scheduled to be vaccinated, or say that they are "very likely" to get vaccinated. This is higher than recent studies from the Pew Research Center reporting that 42% of black and 63% of Hispanic U.S. adults said they would get the COVID-19 vaccine.
"Vaccine hesitancy is a real issue in the communities we serve—especially in communities of color—and we have to overcome a long-standing history of mistrust in the medical system," said Alisahah Cole, MD, CommonSpirit system vice president, population health, innovation, and policy.
Distrust in vaccines in general or fear they may get COVID-19 from the vaccine are the reasons black adults cite for refusing the vaccine, the Kaiser study says.
"With care sites in hundreds of communities across the country, we have an opportunity and responsibility to build trust," Cole said, "and our employees can play a powerful role in encouraging others to get the COVID-19 vaccine, especially in vulnerable populations."
