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.”
The Center for American Progress recently published a piece by Connor Maxwell about how people of color have a greater risk of getting the coronavirus because of structural racism.
Maxwell, Senior Policy Analyst for Race and Ethnicity Policy, Center for American Progress, took time to answer our questions about how and why this is occurring as well as what nurses and other health care workers can do to help.
Why are people of color getting the Coronavirus at higher rates than their white counterparts?
Inequality is magnified in times of national hardship. Occupational segregation has concentrated people of color in frontline essential jobs in industries such as food processing and retail, health care, sanitation, and transportation. Housing segregation has also largely restricted people to densely populated urban areas where crowded grocery stores, public transit, and laundromats are common. Together, these factors contribute to increased racial disparities in coronavirus exposure and infection rates.
Please address the issues with social distancing as well as the economic, health care, and housing systems and how they are contributing to people of color being at greater risk for contracting the virus.
Social distancing is much more difficult for people experiencing occupational, domestic, and urban crowding. People of color are more likely to work in busy food processing plants, grocery stores, and other facilities where maintaining proper social distancing is almost impossible. They are also more likely to live in densely-populated urban areas with less spacious housing and multiple generations under one roof. These factors, combined with insufficient access to accurate and timely information about coronavirus and free testing and treatment, can increase the risk of contracting the virus.
What can state and local governments do to help reduce the risk for people of color?
Here are a few things that state and local governments can do to help reduce the risk for people of color:
- Ensure adequate testing and treatment in areas most vulnerable to the virus.
- Ensure the collection of demographic information upon testing citizens.
- Establish a taskforce at the state level to monitor trends and provide guidance on how to reduce the racial disparities in their state.
Is there anything that nurses and other health care workers can do in order to help reduce the risk for people of color getting the Coronavirus?
Nurse and health care providers need to ensure they are equitably testing individuals coming in seeking health care. They should also support information about COVID-19 being translated in multiple languages so that all patients have access to relevant and important information about how to protect themselves against contracting the virus.
What else is important for nurses to know about this?
Contracting coronavirus is not the fault of individual actions or behavior, but of structures and systems that increase exposure and limit social distancing in communities of color.
With the current pandemic, telehealth is coming in handy as a great way for nurses to “see” their patients and treat them as well as is possible during a nationwide quarantine. That said, there are still telehealth liability issues that you need to keep in mind.
Georgia Reiner, Senior Risk Specialist, Nurses Service Organization (NSO), took time to answer our questions to find out exactly what you need to know to protect yourself and your patients.
What is the most important thing that nurses need to keep in mind when using telehealth—to protect both themselves and their patients?
Telemedicine allows nursing professionals to efficiently and conveniently care for patients. As the provision of health care services via telemedicine expands during the current COVID-19 emergency period, nursing professionals may face new liability exposures.
Nurses must be aware of their organization’s policies, their state practice act, and laws regarding telehealth. It’s their responsibility to know and meet the requirements necessary to provide telehealth services to their patients. When nurses are aware of the risks, they can take steps to protect themselves as they care for others during these difficult times.
Can you give insight into licensing concerns—if they’re treating people over states lines, what do they need to be aware of?
Certain states have different laws concerning when and how telehealth may be practiced, so nurses must check their state statutes, regulations, and policies, as well as state licensure boards regarding practice limitations before initiating services. During the nationwide public health emergency due to COVID-19, some of these statutes and regulations may be waived, so it is important for nurses to be aware of what the requirements are both during and following the emergency period.
Some states require practitioners who engage in telehealth to be licensed in the state where the patient is located and abide by the licensure and practice requirements of that state. Before embarking on interstate telehealth, practitioners must review the state practice act of the state where the patient resides, and make sure that their work falls under the state’s scope of practice in that location.
How can they abide by HIPAA regulations?
Practitioners must comply with HIPAA regulations to ensure the privacy and confidentiality of patients’ data, and keep their information secure. In response to the nationwide public health emergency due to COVID-19, on March 17, 2020, the HHS Office for Civil Rights (OCR) announced that it will waive potential HIPAA penalties for good faith use of telehealth for the time being. This applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.
This notice means that covered health care providers may now use popular applications that allow for video chats—including Apple FaceTime, Google Hangouts video, or Skype—to provide telehealth during the COVID-19 nationwide public health emergency without risk of incurring a penalty for noncompliance with HIPAA Rules.
However, health care providers that chose to use these applications to provide telehealth are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.
Providers may wish to implement additional privacy protections for telehealth while using video communication products. While solutions like FaceTime or Skype may be a good short-term solution during this national health emergency, looking towards the future, providers should seek technology vendors that are HIPAA compliant and who will enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products.
What about informed consent for the provision of telehealth services?
Patient consent is always required prior to participation in telehealth services.
Nurses must obtain a patient’s consent to telehealth services before providing care, which should include an emergency or contingency plan in case of technology breakdown.
Can you give some tips for how nurses can best deliver quality care remotely?
- Increased use of telehealth means that health care organizations and practitioners need to develop guidelines for monitoring telehealth practitioners and sharing internal review information to ensure that high-quality care has been provided.
- Practitioners must adhere to traditional clinical standards of care, and practice within the scope of practice authorized by law.
- Outcome measurement offers practitioners useful information about how well a telehealth program is functioning, including further refinements that may be needed.
- Practitioners must be trained to best utilize telehealth technology, and routine audits of equipment and software functionality must be performed to know how to respond to equipment malfunctions.
- Satisfaction surveys help capture data regarding patient and provider perceptions of the telehealth program, as well as utilization patterns and the overall quality of care.
What should they never do via telehealth? Why?
Nurses must never share patients’ private information—confidentiality must be maintained. Violating patient confidentiality or behaving unprofessionally can result in a complaint filed with the state board of nursing.
Never use a video conferencing application without enabling all available encryption and privacy modes. Some applications, such as Zoom, can be public-facing and could expose patients’ private information.
Please address documentation concerns that nurses may have during this time.
Nurses must document all work performed via telemedicine to avoid potential liability, just as thoroughly as other patient encounters, with both partners to the telehealth agreement contributing to the process.
The American Health Information Management Association, telehealth records minimally should include:
- Patient/client name.
- Patient/client identification number at originating site.
- Date of service.
- Referring practitioner’s name.
- Consulting practitioner’s name.
- Provider organization’s name.
- Type of evaluation to be performed.
- Informed consent documentation.
- Evaluation results.
- Diagnosis/impression of practitioners.
- Recommendations for further treatment.
Whether verbal, audiovisual, or written, all communications with patients must be documented in their unique medical record (electronic medical record or paper chart) in accordance with documentation standards of in-person visits.
Follow-up instructions and any referrals to specialists, the specific interactive telecommunication technology used to render the consultation and the reason the consultation was conducted using telecommunication technology, and not face-to-face, in the patient’s medical record must all be included in documentation in accordance with state and federal regulations.
What else do nurses to be aware of regarding their liability while providing telehealth during the spread of the coronavirus?
The emergence of telehealth capabilities during the current COVID-19 emergency period presents exciting opportunities to address some of the biggest challenges facing health care.
As health care continues to transform with the use of technology and the demand becomes greater, it is essential for practitioners to be aware of the legal, ethical, and regulatory implications to their practice.
Nurses often treat victims of domestic violence. During normal times, they may be able to assist them in getting help to escape their cycle of abuse. But what happens during a pandemic? What happens when they are being told to quarantine? How can nurses assist in this case?
Valerie Weir, BSN, RN, FNE-A/P, CMSRN, SAFE Domestic Violence Program Coordinator and Forensic Nurse Examiner for the GBMC (Greater Baltimore Medical Center) SAFE and Domestic Violence Program, answered our questions to provide nurses with the crucial information they need to help as many victims of domestic violence during this time.
Nurses often see victims of domestic violence in the ER or when they’re admitted. If a patient who is a victim of domestic violence comes to the ER, but is going to be sent home to quarantine, what can nurses do to help?
People currently living in an abusive situation may be at an increased risk for abuse while practicing social distancing and self-quarantine. Often in these situations, they will not have access to their traditional support system and their normal autonomy. Isolation is a key tactic used by an abuser, and a crisis situation provides opportunity for the abuser to exert that control.
Victims will usually wait until they are alone to reach out for help. They will wait for their abuser to go to work and their children to go to school. Currently, that is not an option. Victims are unable to have that conversation when their abuser is in the home; often abusers will monitor the use of cell phones and other electronic devices. The current “no visitor” recommendations in hospitals provide an opportunity for providers to speak with that patient without the abuser being present.
Many domestic violence service providers remain fully functional during the coronavirus pandemic, although they have shifted many of their services to phone and virtual consultations when safe. Shelters and safe house also remain open and have taken measures to keep staff and those living in the shelters protected.
What resources are out there that nurses can utilize?
If you are fortunate enough to have a domestic or family violence program within your institution – use them! That is what they are here for. The SAFE and Domestic Violence Program at GBMC will remain open throughout the pandemic, providing medical-forensic and advocacy services 24 hour a day, 7 days a week.
If you do not have that resource in your hospital, our local community partners are also committed to providing services to victims of sexual and intimate partner abuse. Some have adopted a modified intake process to maintain safety of staff and survivors, and some offices will be closed to the public. But essential staff will be onsite to answer calls and provide services to clients.
Here are some resources available to victims of sexual assault and domestic violence that are available 24/7:
What are the best actions that nurses can take when presented either with someone who has to leave the ER and return home or a patient who is being sent home after a hospital stay? Should they get other health care workers like social workers involved? Please explain.
Listen to the patient. Truly listen. Let them know that they are not alone—you are there for them, and there are others ready and willing to help too. At GBMC, we are fortunate to have the direct resource of our DV Victim Advocates within the SAFE & DV Program. Our victim advocates are ready and available to offer support and resources 24/7. SAFE and DV services at GBMC are free, confidential, and can be anonymous if desired by the patient.
Social workers are an invaluable resource to have involved. They are equipped to provide additional emotional and psychological support, in addition to assisting with safety planning and coordinating any other care and services the patient may need.
What are some things that nurses should *never* do in these kinds of situations?
- Don’t ignore the signs of abuse. As nurses, we are a lifeline to our patients.
- Don’t be judgmental. We may never know the details of someone’s situation, but we can always be caring and supportive.
- Don’t rush, especially during these uncertain times. In order to build and maintain a trusting relationship with your patient, they need to feel heard. Their abuser has likely already filled their head with self-doubt and toxic thoughts. Be aware of that as you are asking questions, they may become defensive. Remain calm and non-judgmental, and allow your patient the time he or she needs to process and discuss the abuse.
- Don’t betray their trust. Inform patients of any mandatory reporting requirements at the beginning of your conversation. In Maryland, to protect patient confidentiality, domestic abuse is not a mandatory report. You cannot report suspected or confirmed domestic violence unless the adult victim consents. Cases involving abuse of a child or vulnerable adult, however, are mandated reports to Child Protective Services and Adult Protective Services respectively.
What else should nurses know for dealing with this situation?
Understand that while imposed isolation is necessary for decreasing the spread of COVID-19, it can also put victims in a more vulnerable position and at a greater risk of abuse.
Don’t be afraid to address this topic with your patient—you may be the only one who does.
Understand that these patients often carry feelings of embarrassment and shame surrounding their abuse. In turn, victims of domestic violence will often discuss their experiences only if they are approached in a non-judgmental and empathetic way. Let them know that they are not alone.
Encourage your patient to reach out for support and assistance. There are several hotlines within each state—and nationwide—that are available 24 hours a day, 7 days a week so patients can make a call at whatever time is safest for them.
When patients have surgery or other procedures in which they have to receive anesthesia, a team works together to ensure the patient’s safety and best care. One of these team members is the perianesthesia nurse.
Terry Clifford, MSN, RN, CPAN, CAPA, FASPAN, has worked in this field since 1991 and took time to answer our questions about it.
As a perianesthesia nurse, what does your job entail? What do you do on a daily basis?
Within the scope of perianesthesia nursing, there are a number of opportunities to serve. From 1991 until 2015, I worked as a clinical bedside nurse in the PACU (post anesthesia care unit). Throughout that time, I often worked as the clinical resource nurse for the unit, not only caring for patients emerging from anesthesia, but helping to coordinate resources within the unit to ensure safe patient ratios, appropriate breaks for staff, etc.
Today, I am the perioperative nurse manager responsible for leadership of 60+ staff members working between the preoperative clinic, the ambulatory surgery unit, and the post anesthesia care units. My current role in perianesthesia nursing includes oversight of unit-based budgets and productivity, staff education and guidance, and active participation in surgical services activities geared at optimization of services and providing quality care.
Why did you choose this field of nursing?
After graduating from nursing school in 1981, I was fortunate to have many opportunities to work in a wide variety of subspecialties, from med-surg, to cardiac rehab, to care coordination, to house supervisor. Upon graduating from a master’s program in 1991, I happened upon a clinical position in the PACU and never left.
It’s an amazing privilege to be able to help guide a patient and family through experiences that can seem frightening, during a time when they are most vulnerable and often fearful. There have been such wonderful advances in the science of anesthesia and pain management that being on the cutting edge of change is always exciting.
What’s the most surprising thing about your job that other nurses wouldn’t expect?
I think one of the interesting things about perianesthesia care is that while we can be confident that we have provided incredible support to safely and competently guide a patient through a surgical or procedural experience, many times the patient does not remember anything. This was disappointing to some nurses who highly value the nurse-patient relationship, but I believe that even in the fog of anesthesia, and the fact that the patient may or may not remember, we do an amazing job of keeping the patient experience a positive one.
What would you say to someone considering this type of nursing work?
I highly encourage staff to pursue their passion—if this is an area of interest, by all means, find a way in!
I think that perianesthesia nursing is the best kept secret in this profession. Every day, I am grateful for the privilege it offers as far as providing safe, respectful care to patients as well as providing safe, respectful leadership to staff.