I had the privilege of being involved in the Frontline Nurses WikiWisdom Forum, a collaborative initiative sponsored by New Voice Strategies, the Johns Hopkins School of Nursing, and AJN to offer frontline nurses a safe place online to tell their stories about the pandemic. We gathered these stories, reflections, and recommendations into a "frontline nurses" report, which offers a "never again" prospectus, clearly laying out what American nurses believe can and should be done to ensure the United States more successfully manages future health care crises. (For the full report, see http://www.wikiwisdom.net/frontline-nurses.)
The nurses' eloquence was often breathtaking and incredibly moving. Nurses who struggled to effectively care for patients infected with COVID-19 expressed great satisfaction in being nurses. These words are from Stacy N., an ED nurse: "I stand poised with my colleagues at the pier, reining in a river with a Dixie cup. And I have never been more proud to call myself a nurse." Stacy's words grace the cover of the report.
Solutions offered by the nurses who posted on the WikiWisdom website fell into two categories: local solutions and national solutions. The local solutions generally apply to hospitals, skilled nursing facilities, or other residential facilities or clinics. In this age of health care conglomeration, fewer unaffiliated hospitals remain, which means that the local solutions also apply to hospital or health care systems. The nurses' proposals are institution based and focus on nurses' work environment and hospital and facility management.
RECOMMENDATIONS FOR LOCAL SOLUTIONS
The first solution listed-"Adequately staff all departments"-rephrases what has become a rallying cry for nurses and nursing unions across the country. The Wiki post from nurse Emily A. describes a workday reality that will be familiar to many nurses: "I'm taking care of these people and haven't peed all day or had time for a sip of water."
"Safe staffing saves lives" is a well-known slogan, and the ideas behind it are well supported by research. But when hospitals became overwhelmed with COVID-19 patients, that phrase took on a broader meaning. As Martha D. noted, "An adequate resource supply is a daily struggle. When I say adequate resource supply, I mean PPE [personal protective equipment], ventilators, doctors, nurses, and support staff of all kinds." Employees cannot work well without the tools and coworkers they need-that seems obvious-but the report highlights how much the frontline nurses felt inadequately supported, whether this lack of support concerned shortages of PPE and ventilators, or nurses.
Nurses also posted on the Wiki about the need for more emotional support at work and for guaranteed mental health benefits in their health insurance policies. Nurses tend to be a tough bunch, but many found themselves at an emotional breaking point and received little understanding from facility management, as Julie S. makes clear: "I am the lifeline between families and the hospital. . . . There is no app that can help address the waterfall of grief I listen to all day. My coworkers have their own stress and we don't have time to talk and process. If you aren't in it, you can't imagine it. My hospital sent me a mental health app-offering me a 10-minute guided meditation of a forest walk. Seriously? This is a mental health emergency." This poignant statement from Lisa T. captures how emotionally stretched many nurses felt: "I'm not one to cry and I had 2 breakdowns. Mostly because of the pressure I'm feeling."
The final two local solutions reached out to management. They asked managers to "give bedside nurses a place at the table and commit to integrating their recommendations," and urged managers to work on developing empathy for frontline nurses, and vice versa, by requiring "administrators and nurses to 'Walk a Day in My Shoes.'" In a time of crisis, it can be hard to understand anyone else's challenges because everyone feels overwhelmed. Nurses want managers to listen to them and understand what they find most difficult on the job, so that when a crisis hits everyone will be better prepared to meet it. Erica M.'s comment about "ghost leadership" makes that point powerfully: "I appreciate that many people, including our hospital administrators, are terrified of contracting COVID, but all of them need to walk at least a few hours in our daily lives. Perhaps they would see the awfulness of our daily lives better and offer more support and be better advocates. I work in a facility where it feels like most leadership, especially senior leadership, are ghosts."
RECOMMENDATIONS FOR NATIONAL SOLUTIONS
The national level solutions in the report include measures that have been absent from the U.S. response: create a pandemic response team and ensure adequate PPE through domestic production and stockpiling. Because the measures taken to address COVID-19 in the United States were politicized, it became impossible for a national response to even exist. States were pitted against each other in bidding wars for ventilators and PPE, and companies were allowed to price-gouge for needed equipment like N95 respirators and surgical masks. The nurses insist the United States cannot have such a disorganized, erratic approach to the next pandemic. We need to develop the governmental infrastructure that would make a true national response possible and effective.
One national solution the nurses came up with may surprise readers of the report: "Make quality health care available to and affordable for all Americans." This was not a political statement, but a practical one. Nurses on the front lines saw that our fractured, profit-based approach to care in this country does not work, or as Kelly Z. put it, "Our American health care system is completely broken. . . . Every day on the news [we] hear about the death tolls, the uninsured who refused to go get help because they didn't have insurance." The nurses wanted every patient who needed care to be able to access care they could afford.
The final two national solutions focus on structural issues and dovetail nicely: "Expand access to and use of telehealth," and "Support a coordinated and collaborative public health infrastructure." Kelly Z. comments on how her infusion center wasted patients' time before COVID-19: "During the pandemic what we learned most as outpatient infusion nurses was how many unnecessary visits we had prepandemic. Patients would come to the city for a lab draw, hydration, perhaps just for a simple long-term follow-up visit. . . . They would spend copays, time, energy, and stress." Telehealth would allow patients to stay in contact with their providers without having to physically be present at visits, making health care more accessible to frail patients or those who live far away.
COVID-19 exposed how poorly this country has supported public health for years. One way to keep hospitals and other health care facilities from becoming overwhelmed during a pandemic would be to use telehealth judiciously, and to promote essential public health measures that would apply nationally. These measures could apply to the distribution of needed equipment and supplies, such as PPE, and work to streamline bureaucracy, making cooperation among and between counties and states smoother.
The wisdom in this report comes from the nurses who contributed, and the nurse thought leaders who helped shape the final document. The suggestions made by the nurses are solid, and in many cases simple, almost obvious. Yet the report highlights how the simple and obvious steps to limit the spread of COVID-19 and better protect nurses and patients were not taken-sometimes because of hospital administrations that couldn't or wouldn't look out for their nurses, sometimes because of failure at the national level. The report expresses a wish: that managers and government officials listen to nurses and implement their suggestions. The ideas offered in the report deserve serious consideration because they showcase nurses' hard-won knowledge of what they, and our health care system overall, most need in order to give patients the quality care they deserve during a pandemic-especially when nurses are also struggling to care for themselves. We hope you will read the report and distribute it widely.