Travel nurses are in great demand right now, as they are helping to relieve frontline workers during COVID-19. While health care facilities are doing everything they can to make environments safe, there are still specific risks that travel nurses are dealing with during this pandemic.
Georgia Reiner, Senior Risk Specialist, Nurses Service Organization (NSO), gave us the latest information about what’s happening with travel nurses, what the risks are, and what they can do to protect themselves.
Are hospitals throughout the country calling on travel nurses to relieve frontline workers? Is the main purpose to alleviate burnout of the frontline workers?
Travel nurses are in high-demand across the United States as hospitals work to treat surges of coronavirus (COVID-19) patients. This crisis arrived at a time when nurse staffing was already a concern due to a multitude of factors, including the growing health care demands of an aging population and nurses aging out of the workforce. Therefore, the demand for travel nurses seems to be primarily driven by a need to build up hospital capacity to handle the influx of COVID-19 patients.
Data from different staffing platforms show that throughout the pandemic, travel nurses are in highest demand in areas most impacted by the coronavirus, like New York and Washington State, and certain nursing specialties like ICU/Critical Care, ER/Trauma, and Med/Surg.
Certainly, as the pandemic continues, the sense of burnout among health care workers will intensify, and travel nurses will likely play an important role in helping to alleviate burnout.
This is a different situation for travel nurses. One risk is checking licensing in different states. What can travel nurses do to be sure that their license transfers? If it doesn’t, but frontline workers are still needed, are exceptions being made?
Before deciding to accept a job, nurses need to ensure that their licenses will allow them to practice in that state/jurisdiction. Multi-state licenses are available for nurses who meet the requirements, which include elements like background checks and education criteria. Temporary licenses are also an option—these are generally reserved for travel nurses who have accepted a job in another state and are awaiting their permanent license.
During the nationwide public health emergency due to COVID-19, some statutes and regulations regarding licensure portability may be relaxed or waived, so it is important for nurses to be aware of what the requirements are both during and following the emergency period. The National Council of State Boards of Nursing (NCSBN) has compiled information about the nurse licensure compact and emergency action taken by states, which is a great starting place for information.
When travel nurses are thrust into an unknown situation in a hospital/medical center that isn’t familiar to them, and they are working with systems they’re not familiar with, what’s the best way for them to cope? How can they avoid burnout themselves? Please explain.
Working in a new environment is inherently stressful. Getting used to new processes, technologies, hospitals layouts, and new people can be overwhelming under normal circumstances, and can be amplified during a crisis like COVID-19. Travel nurses should make sure to take time for self-care to preserve their mental health. This is a stressful time for everyone, so don’t be afraid to reach out to colleagues with questions and for support. Failing to make an effort to cope with these rapid changes can have a negative impact on personal wellness and patient care.
What about a nurse’s scope of practice? what can nurses do to make sure that they are acting in the scope of practice? What if the facility allows them to do more than their own state? Does their scope of practice relate to the state they’re in or the one they’re licensed in, or both?
As the COVID-19 crisis rapidly evolves, travel nurses may be given patient assignments outside of their typical practice areas and locations. When faced with situations that exceed the scope of practice for the state in which they are practicing, or the skills or knowledge required to care for patients, travel nurses, like all other nurses, should develop and implement proactive strategies to alleviate unsafe patient assignments. Nurses need to advocate for patient safety and for their nursing license by speaking up if an assignment does not fall under their scope of practice.
When the assignment is within a nurse’s scope of practice, but not within their realm of experience or training, saying “no” to the assignment could lead to dismissal. At the same time, if the nurse does not feel they are equipped to handle the assignment, they could potentially put patient safety at risk. In these scenarios, nurses should tell their supervisor that they have very limited experience in that area and should not be left in charge. The nurse should describe the task or assignment they don’t feel equipped to handle, the reason for their feelings, and the training they would need to be more confident and better prepared.
What changes have occurred during COVID-19 regarding travel nurses and the risks they face that you think should be permanent either for the near future or forever?
Currently, there are certain state and federal regulations, declarations, and orders that extend liability immunity in the fight against COVID-19. What’s not clear at this time is the breadth and scope of these regulations and orders.
For example, it is not clear if these orders and declarations extend to all providers in all areas of service or if such immunity will be limited and specific to certain types of health care providers. Since there is lack of clarity in terms of immunity, it is prudent for nurses to not presume they have any immunity.
Further, plaintiff’s counsel can file a lawsuit, immunity or no immunity, if the plaintiff’s counsel believes the client was injured and that injury was the direct result of the nurse or other health care professional providing or failing to provide professional services. In the best-case scenario, the suit brought against the nurse will be deemed baseless and their malpractice insurer will work to get the suit dropped/dismissed.
Is there any other information that is important for our readers to know?
The COVID-19 pandemic is still evolving, and there is much we still do not know about the virus. All nurses should continue to follow the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) for updates and guidance to help prevent the spread of the virus and protect themselves and their patients.
With visitors being banned at most hospitals and health care facilities because of the spread of the coronavirus, nurses are often now one of the only contacts that patients have. So how can you help keep your patients calm during this scary time?
Dr. Judi Kuric, academic coordinator for Walden University’s MSN Gerontology Acute Care NP program, and a nurse practitioner board-certified in adult-gerontology, family, and emergency care. She took the time to answer our questions about keeping your patients as calm as possible.
What are the easiest things that nurses can do to help keep patients calm?
Nurses should keep patients informed about their status and treatment plan. There are a lot of scary stories circulating that can increase a patient’s fears about their own condition. Clear, simple, and individualized information will help allay a patient’s fears.
Set expectations and next steps for the patient each day. Identify one or two daily goals to help the patient understand their priorities for the day. Goals could include exercising their lungs by expanding them hourly or walking around the room three times daily.
Provide meaningful distractions such as favorite television shows, movies, or music to entertain and engage the patient and decrease anxiety.
What are some tips that nurses can use to keep patients calm on a daily basis?
Hospital routines and activities like repeatedly checking a patient’s vital signs can increase their stress. Counteract this by providing reassurance on their physical status. Give feedback when their status is stable or better. If a patient’s physical status is worse, help them understand the plan for improvement. Provide ways patients can help themselves and involve them in developing goals. These can be as simple as taking 10 full, slow, and deep breaths every 30 minutes.
Many facilities are playing uplifting songs or classical music throughout the hospital or unit several times a day.
Encourage contact with family and friends using social media.
What can nurses say to patients?
Open, honest, and calm communication is always best. A patient’s imagination can add to their fears about complications or outcomes that may not apply to them. Engage patients in discussions about their fears and try to address each one. Build continuing and meaningful dialogue with the patient by asking them about a family member, a favorite vacation, or their hobbies. This helps you learn more about the patient and also engages them in positive memories.
How should nurses act around them to keep them calm? Confident? Use calming voices?
The stress nurses are feeling has increased in the pandemic. The pandemic means nurses are providing higher levels of care that require additional equipment, procedures, and safety measures. Restrictions on visitors mean nurses must strive to fill the void for conversation, compassion, and smaller tasks that comfort patients.
Avoid passing on your own stress and anxiety. Try to refocus as you enter each patient’s room; use a calm voice, and make sure your activities seem unhurried. Don’t talk with patients about your stresses.
Nurses need to take care of themselves. If your stress level is lower, you’ll be less likely to pass on your worries to patients.
What can nurses encourage family and friends to do to help the patients stay calm and more relaxed? Write letters? Use social media? Facetime?
Now is the perfect time to use social media. Have set times for family members to video chat with the patient, and ask loved ones to send emails or post on social media. If hospital policy allows it, provide the patient with pictures and letters.
It’s important to encourage families to be calm and use their interaction time with the patient to be positive and supportive. This isn’t the time to detail all the anxiety they are feeling or the stressful things happening at home.
In many states, Nurse Practitioners (NPs) can open their own practices. But just because you can doesn’t mean you should. Here’s how to decide and, if you choose to, the types of actions you’ll need to take.
When Scharmaine Lawson, FNP-BC, FAANP, FAAN, had been a nurse for 15 years, she had worked in many different specialties. One of her favorites was home care. In fact, it was her passion.
“I wanted to help my community, and a physician approached me about starting my own clinic/housecall service. It was a ‘right time/right place’ moment,” she recalls.
Lawson ended up founding a VIP housecall practice, Advanced Clinical Consultants in Louisiana, which has been successful for the last 15 years. She also penned Amazon’s number one house call book, Housecalls 101: The Only Book You’ll Need to Start Your Housecall Practice. Finally, she’s designed a course called Housecalls 101, in which she teaches other clinicians how to start and maintain a successful home visit program. Since 2008, Lawson says she has trained more than 600 nurses on how to do this themselves.
“When the opportunity presented itself, it was a natural fit in an environment I felt comfortable operating in,” says Lawson. “Plus, I saw the community need and felt I could best be a servant leader. At the end of the day, the ability to serve is my superpower. It’s an honor that I don’t take lightly.”
Should You Open a Practice?
As Lawson says—and as do our other sources—first, you need to find your passion. You also need to decide if this is something you really can do. “Opening your own practice takes guts, time, and dedication. If you’re missing any of those, it’s not worth it,” says Graig Straus, DNP(c), APRN, CEN, FF-NREMT, founder and owner of Rockland Urgent Care Family Health NP in New York. “I always knew that I wanted to be my own boss, make my own rules, and care for my patients on my own terms. Having that desire really drove me to the point of wanting to open my own business.”
While fulfilling, opening and running your own business isn’t easy. “Nurse practitioners should only open their own practices if they want all the things that go along with owning any business: bookkeeping, marketing, networking, hiring/firing, social media, etc.,” says Bradley A. Bigford, MSN, APRN, NP-C, CCHP, founder and owner of Table Rock Mobile Medicine, PLLC in Idaho. “If they like working 9-5 jobs, owning their own businesses likely isn’t for them. They have to put in long days and nights, weekends, and holidays.”
If you’re up to the task, the next step is to determine what kind of impact you want to have on your community and profession, while making sure that what you want to do matches up with a need in the area you want to serve. “It was a simple decision for me,” says Maurice D. Graham, DNP(c), MSN, APRN, FNP-BC, CEO of Graham Medical Group, a concierge medical practice in Maryland. “As an African American male, [I know that] we are often undertreated for health care issues, accompanied with the fact that African American men do not seek routine screenings and prevention.”
Ask yourself tough, but important, questions. Melanie Balestra, JD, NP, MN, of the Law Offices of Melanie Balestra, is a lawyer and an NP and has been working with other NPs in a legal capacity to help them set up their own practices for more than 25 years. She says you should ask yourself some of the following questions:
- What are the goals of opening your own practice?
- Where will it be located?
- What will be the focus of it?
- Will you take insurances or be cash based?
- Will you need support help?
- Will you be taking out a loan? If so, where will you apply for one?
- Will you be able to function in the red for at least a year?
“The biggest challenge is that it does not happen overnight,” says Balestra. “The NP needs patience and be able to evaluate what might not be going right in the practice. This is why location is important. Collections can be a nightmare, so it’s important to have a good billing and collection service. The biggest mistake is expecting overnight success, and then when it does not happen, giving up.”
What to Do First
The first thing you need to do if you plan to open your own practice is to develop a business plan, says Balestra. “If you are in a state that requires a supervising physician, make sure you have him/her on board. When this is done, hire an attorney who has experience with setting up NP businesses and understands the laws of your state. Hire an accountant to work with the lawyer on setting up the best entity for you legally and tax wise,” she explains. Have several office spaces in mind and make sure they are zoned for medical practices. If you need a loan to start business, it may be a personal loan but a note can be written so that the business pays back the loan.”
Do your research. “Nobody should just open a practice for the sake of opening one without any research into their idea or doing market analysis,” says Lawson. “This is a disaster waiting to happen.”
Bigford stresses that you also need to talk with your family. “It takes a buy-in from everyone because of the significant work it takes from everyone involved and their loved ones to pick up their slack,” he says.
As for how long it will take—for our sources, it took anywhere from four months to two years before they opened their practices.
Straus says that after you incorporate, you should also get a group NPI number—this is different from the personal one you would have gotten when you initially began practicing. “This establishes your company as an organization capable of being recognized by CMS,” he says. He then went and spoke with his local Industrial Development Agency to determine what tax breaks and industry connections he could get. “This will help to reduce costs and potentially hasten any permits needed to build a practice. These are quasi-governmental agencies who have the ability to lessen the tax burden placed on you in the initial stages of opening a business. The goal of these agencies is to promote sustainable businesses and help support local communities.”
You’ll also need insurance—for yourself and your business. “Insurance is a necessity prior to your business opening,” says Emily Keller Rockwell, RN, MSN, CRNP, owner and founder of The Montchanin Center for Facial Aesthetics in Delaware. “Without question, have a detailed meeting with your insurance agent, discussing your business in detail—making sure they understand all aspects of your business and will provide the adequate coverage and limits to protect you and your business.” A few kinds of insurance to discuss, she says, are property, liability, errors and omissions coverage, umbrella, and disability, among others.
Some of our sources didn’t hire staff—at least for the first year. “Staffing depends on the volume of business being generated,” says Graham. “My first year, I didn’t hire anyone. I did all my administration duties and cared for my patients. My goal was to keep my overhead as low as possible without lowering the level of care given to my patients. This worked out well for me.”
Rockwell also waited a year to hire an assistant. Now she has three and a full-time publicist. “I am able to do speaking engagements, conduct trainings, and attend training events to further my professional knowledge,” she says.
If your type of practice requires that you have staff from the beginning, Balestra says to know what you’re looking for in attitude, skill level, and personality.
Bigford says that “Hiring non-revenue generating staff should be kept at a minimum.” When you hire anyone, he suggests that you find people who have a good work ethic. “Someone personable, easy going, and friendly is important,” says Straus.
Once you’ve determined your business, you may need to find a place. (Obviously, if you choose to have a house call business, you don’t need a brick-and-mortar office.)
“Think about the services you want to offer and the space you need to do it in,” says Straus. His urgent care facility needed a lot more resources than a primary care office. “I specifically met with architects who specialize in medical offices to help determine the size and capabilities of the space, based on my needs.”
Graham had one large room that included his own personal desk as well as all the equipment he needed to conduct assessments and provide routine care to his patients.
Rockwell says that when designing your space, keep your clients’ need in mind. “Design a warm, comfortable waiting area to keep patients relaxed,” she says.
All our sources say that you must have a website. Even if it doesn’t bring clients in directly, they will want to look at it to get information about you and the kinds of services you offer.
Don’t discount word of mouth. This can be one of your best marketing tools.
Social media is your friend. Learn how to use it. If you don’t know how, hire someone who does.
When using social media, decide which is best for you. For Rockwell, Instagram has brought her the most clients. Bigford says to go where your core consumers are. His are on Facebook and Instagram. “Post every single day. Go to Facebook groups. Facebook and Instagram ads work really well for me to build trust,” he says.
Straus suggests having “coming soon” ads before you actually open to build up curiosity. “Ads in local papers that cater to your community could be beneficial,” he says. He adds that advertising in church newsletters, school calendars, and through the police athletic leagues—any organization that involves your community—can be beneficial to your business.
Our sources also stress getting patients/clients to give you reviews on Yelp, Google, and Facebook. High ratings attract new consumers.
Before you start your own business, there’s still more to know. “Get experience elsewhere first,” says Bigford. “If you’re trying to learn to be an NP and start your own business, you’re going to struggle at both.” He also suggests that you get traction with patients. It took Bigford about a year to get a steady stream of patients and referrals. “If you have a high overhead in the beginning, you can go out of business before you even see your first patient,” he cautions.
Be sure that you know how to properly manage your time. That was Rockwell’s biggest challenge. “I wanted to see and help every patient who inquired,” she recalls. “I quickly found out that I needed to manage my work time and personal time equally. As with anything in life, you need to reboot or you will burn out. Schedule yourself into your schedule!”
Look for a mentor. “NPs should look for a mentor or someone who has already established a clinic, and pick their brain. That’s what I did,” says Graham.
Have enough money to get you through. “In jobs that rely on insurance, payments are delayed. You do not simply offer a service and get paid the exact moment of exchange. A claim has to be made, filed, and processed. Then payment is issued per contracts,” says Straus. “A solid 4-6 months of cash on hand to cover expenses is needed while you establish your practice, build clientele, and await the beginning of insurance reimbursements.”
Despite all the hard work and sacrifice needed to run your own practice, our sources wouldn’t have it any other way.
Lawson’s biggest reward in having her own practice? “Complete autonomy,” she says. “It is the biggest entrepreneurial superpower.”
Disclaimer: This story is meant to give general advice. For specific individual advice on starting your own business, be sure to consult a lawyer, an accountant, and other professionals.
As the world continues to struggle with COVID-19, many are likewise struggling with the emotional and mental impact that comes with the uncertainty of the pandemic. Seniors, who are in the high-risk group for getting the virus, may be some of the most afraid.
We reached out to Julie Smirl, Assistant Professor in the Online Counseling program at Bradley University, for some ways that nurses can best help seniors during this trying time.
We’re experiencing something unlike anything any of us have ever gone through, and that’s obviously stressful, which weakens the immune system. What are the most important things that nurses can do right now to help protect the mental health of seniors during this scary time?
One important key element to improving mental health as a professional engaging with their clientele is using intentional active listening skills. In working with the senior population for many years, the feedback I have received from my clientele has been that they appreciated a professional taking time to listen to their story, sharing words of encouragement, and the act of human touch on decreasing one’s stress level.
RNs at this time have a unique opportunity to engage with their patients providing reassurance and human touch—even though protective gloves and masks are used, you can still engage in a kind word or touch on their shoulder, etc.—since family members cannot be present during this pandemic. Facing a grave illness and fears about one’s mortality, anxiety and depressive levels will increase. These simple daily practices of encouragement and touch can improve overall mental health symptoms when you come into contact with each of your patients. Keep in mind, some of the patients you are working with may have experienced other traumatizing events in their lives in the past, and this pandemic will trigger many detrimental responses that subsequently will impact their overall health and wellness.
What kinds of things can they say to seniors whom they come in contact with to help reduce their stress?
When talking with seniors, reassuring them that their responses are normal during these uncertain times is first and foremost. Sharing your own fears can assist in normalizing their feelings. Asking them how you can help them decrease their worries—as each person is different in wanting to know about their prognosis for example or having an opportunity to make final plans, if necessary—will help a person feel they have more control over their current health dilemma.
What additional actions can they take?
If they ask for other assistance make these available such as Pastoral Care departments, or legal assistance, financial aid, etc. can all lead to decreasing one’s stress levels knowing their COVID symptoms may impact their mortality rates and their families both physically, emotionally, and financially.
If nurses work in nursing homes/rehab centers—and seniors are potentially with someone who have been exposed—how can they help to keep seniors’ spirits up? What actions can they take?
Provide ways seniors can still participate, perhaps virtually, in activities can boost spirits. Provide activities that they can do in their room with their roommates. Find ways family and friends can connect through a window to their room, or technology/phones, etc. that they may not have personally will assist with social engagement. There are many games you can participate in keeping social distancing requirements in place.
What precautions should be in place to prevent the elderly from feeling lonely or isolated right now?
Having access to technology such as computers, smart phones, etc. is helpful so that they can connect with family and friends since they cannot leave the facility, and visitors cannot come to see them. Encourage them to call someone daily. Turn off the TV if they are focusing on the news all day—which can keep their anxiety and depression levels high. They can check once or twice a day to receive the news. Sitting out on their patio keeping social distancing guidelines and wearing masks, can still provide a boost to their moods and distract intrusive thoughts.
Suppose nurses do home health care. What can they do to make their senior patients feel better?
Similar to being in a hospital, residential, or home settings, encourage them to connect daily with a friend or family member to create connections with others. We are social beings by nature and being isolated can increase anxious and depressive moods in anyone.
What are some things that nurses should never be doing in these kinds of situations?
It is not helpful to tell someone who is scared or hurting, that they should not feel that way. This invalidates their feelings about what is occurring both internally and externally in response to stimuli. Feelings are important as they provide a label for our perception of what is occurring in our lives from our worldview and also lets other people know what our perspective is on what we are experiencing. Taking time to understand your patient’s cultural background can also provide helpful information on how to approach your clients without incurring more harm to their mental health by acting contrary to their cultural belief system.
What else should readers know?
Taking time with each patient who is an older adult can have a very positive impact. Often, they are afraid and cannot hear or see well. If professional caregivers are hasty in their movement during the provision of procedures they are performing, not taking time to explain each step they are taking, then anxiety levels will increase. Fear or flight/fight responses will have a negative effect on patients’ ability to build up their immune system and will potentially deplete one’s ability to recover.
In 2014, Melisa Wilson, DNP, ARNP, ACNP-BC, the Clinical Operations Director and Pulmonary Hypertension Program Coordinator at AdventHealth Orlando, discovered a lump in her breast. Fearing a cancer diagnosis, her husband encouraged her to see her doctor immediately.
Wilson nearly didn’t. After all, she didn’t have a family history of breast cancer. She thought it was a mammary duct drying up as she was pumping breast milk less for their child.
Thankfully, she listened to her husband. An ultrasound led to a biopsy and then a diagnosis.
“I was taken entirely by surprise. The journey was swift from the time we felt the lump to diagnosis—just eight days. I did not expect to hear, ‘I am sorry, Mrs. Wilson, you have breast cancer,’” Wilson recalls.
Wilson’s diagnosis was Stage IIB HER2 positive, and for the next 18 months, her treatments included Herceptin, Perjeta, Carboplatin, Taxotere, and Neulasta. Her inspiration was her son, who had been born at 23-weeks. “He fought for his life, and in turn, it inspired me to fight for mine,” says Wilson. “My faith in God got me though.” She also had tremendous support from her family, work family, friends, and her oncology team, including her NP, MD, and LCSW.
The most challenging part of her journey, Wilson says, was financial. “The bills for oncology treatment came in quickly and were very high. I maintained my full-time job as a nurse practitioner, though, with some accommodations. I would work up to the day of chemo, take six days to recover, and then return to work for another two-week cycle,” she recalls. “It was hard, and the bills would be overwhelming to deal with at times. I remember being at chemotherapy and getting a call asking me to pay several thousand dollars to pay for a test I needed.”
Wilson beat the cancer, and she says that she now can more easily empathize with her patients because of what she’s experienced. “As an NP, I can relate to my patients on so many different levels. My patients have a rare cardiopulmonary disease—pulmonary hypertension. Most have no idea what pulmonary hypertension entails,” she says.
A few years ago, Wilson says, she had a patient who was scared about having a line placed in her chest. This needed to be done for infusion of pulmonary hypertension treatment. The patient experienced a lot of pain due to being on a subcutaneously infused machine. “One day I called her and asked for her to come in for an office visit with me. I explained that I had done as much as I could to manage her pain, and she needed to consider a different route of infusion. She was tearful and upset. She was concerned about her body image,” says Wilson. “I showed her my port, though it was different and showed her my head, which was hairless due to chemo. I told her, ‘I understand what it is like for your body to change in front of your eyes, but these are the things we do to survive.’ We cried together, and she went on to have the line placed.”
Just recently, Wilson says that her mother was diagnosed with breast cancer. Wilson believes that she went through her journey so that she can help others and that cancer taught her how to live and not be as fearful. “My tribulation shaped me, and now I help my Mom. I am happy to be her advocate,” says Wilson. “Being there for her and not feeling helpless is rewarding. I know it gives her comfort.”