Nursing is a profession of service to others. Daily, nurses meet the physiological, psychosocial, and spiritual needs of the patients and patients’ significant others to whom health care is provided. The provision of quality, safe, evidenced-based practice nursing care is delivered by nurses in both inpatient and outpatient health care settings. However, the provision of nursing care can be significantly impacted when nurses are not provided safe environments to work within.
In 2018, I had the opportunity to work with my fellow nursing colleagues on the American Nurses Association (ANA) Professional Issues Panel #endnurseabuse. The panel was an advisory committee consisting of nurses throughout the United States. Our mandate, to critically and honestly discuss workplace violence perpetrated against nurses. I commend the ANA on their stance on violence against nurses in the workplace perpetrated by such entities as visitors, patients, intimate partners, nurses-to-nurses, and others, as well as their 2015 position statement on bullying, incivility and violence within the workplace. In 2019, Ambrose H. Wong, M.D., MSEd, Jessica M. Ray, PhD, and Joanne D. Iennaco, PhD, PMHNP-BC, APRN, noted in an article written within The Joint Commission Journal on Quality and Patient Safety, that “Health care workplace violence is a growing, pervasive, and underreported problem.” Of concern is that despite the identification of the problem of workplace bullying and violence, it remains an ongoing issue.
Enough is Enough
Workplace violence can consist of both physical and psychological threats against others. While bullying can become physical, perpetrators tend to use negative words (i.e., humiliation, backstabbing, verbal abuse) to gain psychological intimidation over their victims. In February 2019, as I sat within a Sigma Theta Tau International conference on healthy workplaces breakout session, a normally quiet person, I found myself verbalizing the words, “Enough is Enough,” as stories were shared of working with disrespectful nurse colleagues in clinical and academic settings. I have been a nurse for over 29 years and became a nurse to administer care to the physically and mentally ill. It is a privilege to help in the healing process of others. If I would have known that violence and bullying was tolerated within the nursing profession as a normal ritualistic patterned behavior, I may have rethought my entry into health care.
Alas, I am a nurse for life. And although I have contemplated leaving the profession I never will. The truth is, I love being a nurse and I love caring for patients. And, I enjoy the collaboration that occurs with my colleagues that leads to positive health outcomes with patients we jointly care for in clinical settings.
And so, I am challenging my nursing colleagues in clinical and academic settings, nursing leadership, and nursing health care organizations, to take back our profession by deeming violence and bullying in nursing as not being acceptable. By ignoring violence and bullying in the workplace, nurses perpetuate the cycle of anger and violence. The co-existence of anger and violence in health care environments will continue if nurses do not deem these behaviors as harmful to our profession. As a profession of caritas that places the safety and health of others as a priority, we must take this professional ideal and transfer it not only to the care of our patients, but our care for one another.
Ways Nurses Can End Violence and Bullying
Nurses are wonderful advocates for patients. Let’s become advocates for one another. If you observe bullying or violence within the health care environment, report it (i.e., notify your immediate supervisor, nursing leadership, and human resources). Calmly acknowledge that you have observed the behavior of the perpetrator and affected nurse and ask, “Can I assist the two of you in anyway? There appears to be a disagreement of some kind.” This places the bully or potentially violent person on notice that others have witnessed their behavior.
Nurses can educate themselves on how bullying and violence presents itself in the workplace by becoming familiar with the ANA Code of Ethics with Interpretative Statements, the United States Department of Labor Occupational Safety and Health Administration (OSHA) workplace guidelines, and The Joint Commission’s stance on workplace bullying and violence. Additionally, there are now several nursing articles that can provide further insight on behaviors that can negatively impact health care environments, health care workers, and patients. A list of current websites is provided in the sidebar for your reference and support.
Together, nurses united can create healthy and supportive workplace environments for all!
On its own, addiction can feel isolating. When coupled with “stay-at-home” mandates put in place to help quell the spread of COVID-19, living with addiction becomes even more challenging. Health professionals must evolve with mandated changes in order to better help the more than 21 million Americans living with a substance use disorder (SUD).
Yet, that number isn’t even close to the entire story when it comes to addiction treatment. Of those who have an SUD, only about 1.4 percent of those aged 12 or older receive treatment during any given year. That glaring treatment disparity stems from a number of factors including access to economic, medical, and social support. The biggest hurdle to comprehensive addiction treatment isn’t lack of insurance or clinic inaccessibility. Ultimately, a struggling addict must want to recover and be ready to do what it takes to achieve their goals.
As addiction varies significantly among individuals, addiction treatment can look very different depending on the person and their preferred substances. SUD treatment can occur in inpatient or outpatient settings. Sometimes, more clinical support is needed, especially among opioid addicts and those dependent on alcohol. In most cases, support groups are crucial to the recovery process, and the sudden onslaught of COVID-19 has completely upended the support system for recovering addicts across the world.
What We’re Up Against
Even if you know firsthand what it’s like to work at an addiction treatment center, COVID-19 has changed everything. Now, health care professionals must work to provide holistic care in what amounts to a vacuum, but addiction treatment involves every aspect of patient care, from mind to body and beyond, and human interaction is a cornerstone of recovery.
Depending on an addict’s substance(s) of choice and the severity of his or her condition, addiction treatment can include a variety of factors. In the wake of COVID-19 and widespread social isolation mandates, treatment may be even more crucial to those vulnerable to relapse. Accessing treatment facilities and medications may inadvertently put many addicts at risk, especially opioid users who may require access to methadone as part of their treatment plan.
Isolation itself can even be a relapse trigger, making social isolation mandates a real threat to recovering addicts. It’s important to note that triggers among opioid users may be similar to those of alcoholics. These triggers include isolation, stress, and anxiety. Furthermore, both opioid addicts and alcoholics may face dangerous withdrawal symptoms when attempting to quit on their own. Without addiction treatment clinics as an option, opioid addicts and alcoholics may fall through the cracks, unable to break free from their addiction. Telemedicine may offer a solution, even in the face of a global pandemic.
Embracing Telehealth in the Wake of Disaster
Telemedicine isn’t new in the realm of addiction treatment, but its use has surged in popularity during the first few months of 2020. Using telemedicine, patients can access care and various clinical services via telephone or video chat. For many recovering addicts and those with co-occurring disorders who are practicing social isolation, telemedicine is a vital aspect of the healing process.
Even without the threat of a pandemic, telemedicine is beneficial to patients from all walks of life, especially for those in rural areas with limited transportation options. The elderly and infirm may also find benefit in telemedicine, which is just as viable as traditional care. In fact, a 2019 survey found that 61% of patients believe they received the same quality of care via telemedicine as with traditional in-person visits. Telemedicine combines quality care with human interaction, benefiting addicts in all stages of recovery.
Especially for those in early recovery, support from one’s peers and treatment providers is integral to the process; however, social distancing has eliminated that lifeline virtually overnight. Telemedicine is poised to bridge the gaps. Early recovery is defined as an addict’s first year of recovery, and it’s considered a crucial time for those looking to change their life for the better. During this time, addicts are learning how to cope with their emotions in a healthy manner while also avoiding relapse triggers and behaviors.
Adaptation and Perseverance Against Addiction
While deaths and illnesses related to COVID-19 are headline news among the general population, health care providers in the realm of substance abuse have additional concerns. Scrambling for solutions, addiction treatment providers worry that social isolation will result in increased relapses and overdoses.
Recovery clinics are urging addiction treatment providers to perform regular wellness checks via remote channels and telemedicine. Health care providers can also encourage their patients to attend virtual support groups and 12-step meetings. Alcoholics Anonymous, for example, is utilizing various meeting apps such as Zoom to facilitate online meetings for those in recovery, and all addicts are welcome to participate.
Fighting opioid addiction and other forms of substance abuse can be an uphill battle, and social distancing mandates are further compounding the issue. It’s essential that health care providers don’t overlook their vulnerable patients with SUDs. Those who are in recovery often rely on group support and find social isolation to be a relapse trigger, so it’s imperative that treatment clinics and providers offer alternatives so their patients feel supported in these trying times.
News of a global public health concern like COVID-19 (Coronavirus) can naturally trigger overwhelming feelings of uncertainty and anxiety that can ultimately impact one’s mental health.
Countless individuals worldwide are dealing with sudden changes to their regular schedules leaving many people unemployed, depressed, and apprehensive about their future.
Due to the unprecedented nature and ever evolving news surrounding COVID-19, it is completely expected and appropriate to experience fear and trepidation during periods like these.
Despite these difficult times however, it is also imperative to know not only how to effectively manage potential anxiety but also mitigate negativistic ruminating thoughts from affecting your overall mental health.
Because of this, here are some useful mindfulness exercises that may be beneficial in reducing stress and anxiety associated with the COVID-19 pandemic:
Breathing is an important component of mindfulness. Whenever you are stressed or overwhelmed, take a moment to relax and simply focus on your breathing.
Slowly inhale and exhale, releasing your tension and stress away with each breath and regain control over how you choose to respond to the situation at hand.
Remember, you are the master of how you choose to interpret the world around you.
Start by closing your eyes and choosing a comfortable position. You can either sit on a chair or lie on your bed.
Once you are breathing comfortably, slowly move your awareness through your body, focusing on one area at a time.
Stop whenever you find an area that is unusually tight or sore and focus your breath on this area until it loosens.
Feel free to use a calm and healing visualization at this point as well (e.g., a ball of white light melting into the sore spot) to help facilitate the healing.
Hold an object that is special or interesting to you.
Focus all of your senses on it and note the information your senses feedback to you, including its shape, size, color, texture, smell, taste, or sounds that it makes when it is manipulated.
Practice this meditation technique daily and feel free to bring this object with you to work or school as this can be an especially helpful tool in grounding you to the present moment.
Like the previous exercise, this exercise can also be completed with all your senses while you focus on eating a particular food that you enjoy, like dark chocolate or a grape.
Eat slowly while utilizing all five senses: smell, taste, touch, sight, and even sound to ease you back to reality.
Lastly, take a leisurely walk at a gentle but familiar pace. Observe how you walk and pay attention to the sights, sounds, and sensations around you as you walk the road ahead of you.
Notice how your shoulders feel, the sensations in your feet as they meet the ground, and the swing of your hips with each stride.
Match your breathing to your footsteps and allow yourself to be immersed with the environment around you and use this time to consider the stressful situation in a broader context and keep a long-term perspective.
While the current COVID-19 pandemic can trigger feelings of uncertainty and fear, it is also important to look for opportunities during these especially difficult times to practice patience and kindness.
Use this opportunity to celebrate successes, find things to be grateful about, and take satisfaction in completing tasks regardless of how big or small.
Because in the end, your mental health is important and it needs to be protected.
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.
Since it impacts us, every household is encouraged to complete the 2020 Census. The U.S. Congress started taking the U.S. Census in 1790, as noted in the U.S. Constitution. The Constitution also required that the federal government do the census every 10 years. Political power and funding are greatly impacted by the census, which also impacts all the elements that contribute to the social determinants of health. The census is used to allocate congressional seats, electoral votes, funding for government programs, as well as the database of a lot of research.
More than $675 billion federal funding is distributed yearly based on the U.S. Census. Accuracy in the “count,” counting the correct category, clear descriptive verbiage, and engagement are imperative. Relating the importance of completing the census to all stakeholders, and creating an environment where people feel safe in completing the census, especially marginalized populations, is essential. Minorities, children, immigrants, and low-income areas are noted to be difficult to count.
Accuracy of the count has always been a concern from day one. President Washington and his Secretary of State, Thomas Jefferson, shared concern that the Census of 1790 undercounted the population greatly—and we still have this issue today. According to the U.S. Census Bureau, the first Census consisted of six questions: the name of the head of the family, free white males at least 16 years old, free white males under 16 years old, free white females, “other free persons,” and slaves. Slaves were counted as three-fifths of a person and Indians were not counted until almost 100 year later.
The 2020 Census has had a hot debate over including a citizenship question and the negative impact it would have. Although the suppressive citizenship question will not be included, citizenship numbers could be extracted from the yearly American Community Survey (ACS), which falls under the U.S. Census Bureau. We still deal with inaccuracies of the census, concerns of undercounting the population, as well as debates over the questions included on the census. The census has a huge impact on the allocation of funding, research, and political representation.
African Americans and Latinos have been historically undercounted. These groups are even ranked by states in census tracks called HTC (Hard to Count) with New York, Texas, Florida, California, and Georgia in the top five states respectively for African Americans and for Latinos, it is California, Texas, New York, Arizona, and Florida, respectively, according to CensusCounts.org. Children also have a ranking in HTC states. Many elements play a role in why the census does not reflect an accurate count or low survey participation with minorities, low-income, children, and immigrant population. Fear, distrust, inequity, lack of information, privacy, and intent contribute to poor participation.
The 2020 Census adds a new element that for some may be a barrier and/or learning curve, which is technology. For the first time in history, the census will be available online. The addition of media brings about many issues, such as computer literacy and internet access issues. The HTC marginalized population should be targeted for support and resources to get optimal participation in completing the 2020 Census.
The U.S. Census data determines our political representation. Congressional seats for each state are determined by census data. As a result, a state could lose a member in Congress or your city could lose state representation. For example, the House of Representatives divides its 435 memberships or seats among the 50 states based on the total resident population (citizen as non-citizens) using a 1941 calculation methodology; a complex process. Let’s not forget two important political terms: redistricting and gerrymandering. Redistricting is the period where legislative boundaries are redrawn. The data is used to define legislative districts, school district areas, as well as other areas in government. Gerrymandering is a method that officials may use to draw district lines to influence election results, manipulating boundaries and changing voting districts to favor a political group.
Census data is used to make decisions on road repair, schools, services, jobs, education, neighborhood improvements, and more. As noted above, more than $675 billion federal funding is distributed yearly based on the U.S. Census. According to the College Board’s annual Trends in Student Aid report, in 2017-2018, there were 7 million Pell grant recipients equaling $28.2 billion. In 2016-2017, 49% of Pell grant recipients were dependent students; 37% of these students came from families with incomes of $20,000 or less, and another 36% came from families with incomes between $20,000 and $40,000. Funding is allocated in one of three ways: selection and/or restriction of recipients, award allocation, and monitoring and assessment of program performance.
Medicaid, for example, is the largest source of health insurance for low-income and disabled persons. It’s a federal and state program where funding and reimbursement level calculations include the state’s population and income levels, which are derived from the U.S. Census.
The Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) serves low-income women, infants, and children at nutritional risk by providing nutritious foods and health care referrals. WIC provides vouchers for crucial foods like baby formula, eggs, milk, and fresh fruits. According to the Food and Nutrition Service, in 2018, WIC served approximately 6.87 million (5.5 million being children and infants served). For the first five months of FY 2019, 6.4 million had been served. WIC uses the Health and Human Services (HHS) guidelines for WIC eligibility. WIC uses the Consumer Price Index, which is derived from the U.S. Census, to see monthly food voucher prices and the ACS (which is also part of the Census Bureau) to allocate funds to each state. By the way, the U.S. Department of Agriculture reported that in 2016, 58.6% of WIC participants were white, 20.8% Black or African American, 10.3% American Indian or Alaskan Native, and 4.4% Asian or Pacific Islander.
We often look to the Centers for Disease Control and Prevention (CDC) for data collection and research; from tracking diseases and prevention to program evaluations for effectiveness. It is accepted as vetted, accurate information; as well as the guardians of public health while utilizing this data. The National Health Interview Survey (NHIS) is the methodology used for this data and it is based on the decennial census information and updated with every census.
Many sources that track the social determinants of health, such as income and poverty level, use census-derived data. The Current Population Survey (CPS) is one of these sources, collecting data since 1940. CPS, sponsored by the U.S. Census Bureau and U.S. Bureau of Labor Statistics, provides information about our jobs, earning, education, and other studies that note the population’s social well-being, such as volunteerism, child support, and health insurance coverage. A huge impact of CPS is obtaining the number of unemployed population and the demographics. Unemployment data and economic data are used by policymakers to address unemployment and the repercussion of it.
One of the largest, well-known research projects commissioned by the Institute of Medicine was published in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The Institute of Medicine used data from the U.S. Census throughout this research. This study concluded, “Evidence of racial and ethnic disparities in healthcare is, with few exceptions, remarkably consistent across a range of illnesses and healthcare services.” This study confirmed what people of color have always known through personal experience, but validation by a scholarly entity through research was priceless. This research has impacted health care delivery and highlighted the realization that care is not equal, and inequities exist which we must address.
A complete and accurate count of our population by the U.S. Census is imperative. The U.S. Census data impacts many elements of life, especially funding, representation, and research. Federal funding allocation dictated by the U.S. Census affects our classrooms, jobs, senior services, health care in our communities, and numerous other programs and services. This includes health insurance programs like Medicaid; as well as WIC and Head Start. Hence, the U.S. Census impacts health care disparities and the social determinants of health as well.
Minorities and low-income people are undercounted and noted to be difficult to count for many reasons, yet census data impacts this population greatly. Our political representation and redistricting is based on the census data and being counted dictates the number of representatives. Our elected officials, our representation, advocate for funding and represent us in all issues that impact life, liberty, health, and even our pursuit of happiness. Research drives the allocation of funds, health care delivery and changes, social issues and justice, just to name a few areas in which the US Census Data is used as a resource. Funding dictated by the census impacts our classrooms, jobs, grants, and health care in our communities—especially vulnerable, underserved populations. Since the U.S. Census impacts us all, we must encourage everyone to complete it.
We are in the first quarter of the year and none of us expected or envisioned that we would be dealing with the course of events happening now. It is almost surreal, like a scene from a movie. Many people entered the new year with the desire of having new goals, resolutions, and dreams. This was to be the year signifying “2020 Vision” seeing things more clearly. Everyone stated “this is going to be my year.” What we are going through now has been a real eye-opening experience.
Over the course of history there have been many epidemics, disasters, and social issues, which were usually contained in one region. People may have felt safe thinking, “it is not happening in my city, state or my area of the country.” These past three months, the “Coronavirus pandemic” has affected all U.S. states and multiple countries, and crossed every race, age, and socioeconomic group. This blog is not going to be filled with statistics, because we are bombarded daily from all media sources with the data. Updated information should be obtained from reliable sources such as the CDC (www.cdc.gov) or WHO (www.who.int).
This “global shutdown” has affected every aspect of human life. Freedom and things that we took for granted, such as shopping, going to the movies, dining out, visiting amusement parks, playgrounds, attending concerts, festivals, hanging out with friends and family, and most of all traveling has been brought to a screeching halt. Now families are going to have to learn how to spend more time with their families, reflecting on things to be thankful for and creating entertainment and meals at home.
For safety, government officials have issued “Stay at home” and “Lockdown” mandates, limiting travel for only essential needs. The goal is to try to decrease the spread of the virus, especially to vulnerable populations; hence a new term has been coined “social distancing.” Everyone is to keep a 6-ft distance from each other and limit gatherings of people to 10 or less. Social distancing is a physical separation and does not mean that you cannot communicate with others. The one positive note is that in this age of technology we all can stay connected to others whether they are in the same city or across the country.
Social distancing is important, but there are two populations that this may have an adverse effect on, those with mental illness and those that are in abusive relationships or families. Social distancing could cause “social isolation” and those with depression could have an increased risk of suicide. The worst thing is having individuals quarantined in the home with their abusers. If you know anyone that is in an abusive situation or has mental health issues, reach out to them, if possible.
We are not sure when this pandemic will come to an end, so during this time find ways to decrease your anxiety and stress and try not to panic. Some things that you can do is continue to exercise, keep your humor (in light of what’s going on), watch movies, create crafts and cook together, and make sure to reach out to those that may be alone.
May this pandemic not dim our vision. Stay calm, stay focused and productive.