As you, the reader, prepare to immerse yourself in an informative and impactful OJIN topic focused on the COVID-19 pandemic and the global profession of nursing, I invite you to pause. I invite us all to pause and – both as individuals and as a nursing community - to reflect on what this chronic period of change and uncertainty has meant for you in your life and in the lives of those you love. The COVID-19 pandemic has left no one among us untouched. For many, the past year and a half has been informed by hardship, fear, loss, and grief. This crisis period has also been accompanied by long overdue discourses and responses to social inequalities, health inequities, and structural injustices. As we pause around the struggles confronted, as well as the lessons learned, let us also remember with deep appreciation our dear colleagues who have died in the line of service throughout the pandemic. While reading this very special series of articles, we honor their courage, their commitment, and their healing legacy to nursing at a time when the world needed them most.
The COVID-19 pandemic has also been a time of hope. I have consistently been inspired by nurses locally and globally who have showed up to do the best they can with the resources and information they had available at any given moment. I have been humbled by stories of nurses helping family members to say good-bye to their dying loved ones by phone or tablet when visitor restrictions prevented bedside visitation. I have wept alongside friends and colleagues who have struggled to believe that they were doing enough for their patients and communities. I have applauded nurse advocates and disruptors who have called out the need for informed action, measurable change, and system-wide progress on social media and in the mainstream news circuit. Mostly, I have been beyond proud to be a member of the most trusted profession who has delivered high-quality healthcare to the public at the intersection of science, compassion, and ethical fortitude amid overwhelming instability.
Much of my focus during COVID-19 has been on increasing access to palliative care during this mass global surge in serious health-related suffering, bereavement, and death. In many ways, both primary and specialty palliative nursing has been the core of COVID-19 care (Paice et al., 2021). The World Health Organization (2020) estimates that there are roughly 28 million nurses globally who account for 59% of the health workforce. If each nurse working in every health and social care context - from acute to long-term care facilities, to schools, prisons, and the community, to research and academic spaces – was equipped with primary palliative care skills in symptom management, communication, spiritual care competencies, and cultural and structural humility, as well as the ability to navigate complex ethical dilemmas, think about the impact nurses could have to effectively bear witness to suffering and then to alleviate it. Realizing such a vision will require nurses to integrate palliative care into their clinical practice specialties (Rosa, Dahlin, et al., 2021; Rosa, Ferrell, & Wiencek, 2020); advocate for palliative care access throughout the serious illness trajectory as a human right and moral priority (Rosa, Ferrell, & Mason, 2021; Rosa, Pettus, et al., 2021); recognize and form the multisector partnerships needed to expand palliative care service delivery (Rosa & Davidson, 2020; Rosa, Krakauer, et al., 2020); and fully incorporate palliative care training and research initiatives throughout professional education and development (Rosa, Ferrell, & Mazanec, 2021; Rosa, Gray, et al., 2020; Rosa, Meghani, et al., 2020).
But no matter the skills we obtain or our intentions to improve the health of the public, the workforce will undoubtedly fall short of its aspirations if nurses and the systems in which we work do not attend to our individual suffering. The COVID-19 pandemic has called nurses everywhere to have honest and transparent discussions about how our work in the crisis context, and the barriers that prevent us from effectively achieving our responsibilities, is distressing us as human beings. Burnout, trauma, emotional distress, professional grief, and moral suffering have all conspired to create unsustainable work environments and increased turnover. The solutions go beyond mere self-care and will require excavating and re-envisioning the structures that undergird professional identity, health system priorities, work cultures, and fiscal investments in nursing, among other areas that impact nurse safety and well-being.
The contributors in this OJIN topic provide substantive guidance and expert insights during a time when many of us are holding both the despair and pain of the past year, but also the hope of what might be. With attention to the best available evidence, the authors also give readers a broad overview of the challenges that have confronted nurses and healthcare during COVID-19, as well as solutions to move us forward. Millenbach and colleagues start this topic with a critical study on the, “Impact of the COVID-19 Pandemic on Nurses: Where is the Financial Safety Net?” While demonstrating the pandemic-related financial distress of nurses and highlighting the need for financial safety nets, they show how short-term emergency grant funding exceeding $2.7 million through Nurses House, Inc. – supported by the American Nurses Foundation – has made a tangible difference in the lives of 2,484 nurses across the United States. In addition to pragmatic practice implications and a frequently overlooked discussion on the financial well-being of nurses, the authors frame the article through the lens of Watson’s Theory of Human Caring, grounding readers in the primary ethical tenet of the profession.
With an emphasis on both immediate and long-term action planning to support the nursing workforce in the article, “The Impact of COVID-19 on the Nursing Workforce: A National Overview,” Chan et al. provide a broad-based, national-level overview of the varied impacts of COVID-19 on nursing. Using the HealthImpact Workforce Strategy Model, exemplars are provided to empower readers with the knowledge needed to improve workforce domains through strategy, education, research, and policy. Their discussion of expanding the scope of practice for advanced practice nursing foreshadows Bischof and Greenberg’s manuscript on reimbursement parity for nurse practitioners (NPs). While the need for increased health services during COVID-19 led to the removal of many practice restrictions for NPs, there are a still of number of reimbursement and future policy considerations that must be addressed in the wake of the pandemic. As Bischof and Greenberg emphasize in “COVID-19 and the Case for Reimbursement Parity for Nurse Practitioners,” reimbursement parity between NPs and physicians is more important than ever.
With global school shutdowns and a broad range of psychosocial effects on the world’s children, school nursing has moved to the forefront of public health advocacy efforts. In “Through the Looking Class: Reflections from Three School Nurses Amid the COVID-19 Pandemic,” authors Grano, Gavin, and Cogan reflect on the school nursing stance, offering advocacy guidance and action steps that will assist stakeholders in increasing school nurse access and presence in key areas. As school nurses continue to play leading roles in COVID-19 mitigation and contact tracing, these authors describe their experiences and leadership from the perspectives of their New Jersey practice settings.
This issue would be incomplete without the in-depth description of COVID-19 vaccination efforts by Marcus, Danielson, and Frenkel. Integrating a comprehensive perspective on vaccination history and lessons learned during previous outbreaks, in their article, “Vaccination During the COVID-19 Pandemic: What Nurses Need to Know,” the authors address emerging technologies, vaccination barriers, successful vaccination programs, and vaccine hesitancy among healthcare providers. With attention to COVID-19 vaccine concerns, the authors equip nurses to serve as agents of vaccine information within their frontline worker and responder capactities.
Both social justice and public health nursing make pivotal appearances in this topic. Flagg and Campbell, in “COVID-19 in Communities of Color: Structural Racism and Social Determinants of Health,” focus on structural racism and the social determinants of health that are urgent issues at this time in the pandemic and our national narrative. Black, Indigenous, and People of Color (BIPOC) communities have been disproportionately and disastrously impacted by COVID-19. These authors emphasize not only the structural factors that contribute to and sustain disparities (e.g., economics, policing and carceral systems) but also strategies for nurses to address racism, which they keenly identify as “the ultimate underlying condition.” However, health equity will continue to elude the health system if community-based and public health nursing are not consistently and strategically invested in, according to the article, “Rebuilding Community-Based and Public Health Nursing in the Wake of COVID-19,” by Pittman and Park. Their analysis of data from the National Sample Survey of Registered Nurses and the National Association of County and City Health Officials drives their recommendations to increase nursing education offerings in community and public health settings and advance policies that will address compensation shortfalls.
Becker closes out this topic with the article, “Assessing Patient Ability to Exercise COVID-19 Transmission Based Precautions: A Proposed Clinical Tool,” in which he describes a proposed tool that nurses working in myriad contexts will find incredibly useful: the Transmission Based Precautions Inventory. Consolidating and leveraging the behavioral health aspects of COVID-19 transmission, including chart review and the clinical interview, the inventory is a tool that would inform discharge decision-making and optimize safety considerations. While the need for the recommended tool is clear, the author invites reader feedback to inform future development and implementation processes.
The articles in this topic are a gift to nurses and nursing everywhere. With great care and firm reliance on the evidence base, these authors provide an excellent overview of many of the challenges and opportunities that lie ahead of the nursing profession in this COVID-19 era. As you embark on the knowledge offered in this topic, I invite you to consider the following words from poet and psychoanalyst, Clarissa Pinkola Estés, PhD.
In any dark time, there is a tendency to veer toward fainting over how much is wrong or unmended in the world. Do not focus on that… We are needed, that is all we can know… One of the most calming and powerful actions you can do to intervene in a stormy world is to stand up and show your soul. Soul on deck shines like gold in dark times… When a great ship is in harbor and moored, it is safe, there can be no doubt. But ... that is not what great ships are built for (Estés, 2020, paras. 7-10).
The journal editors invite you to share your response to this OJIN topic addressing COVID-19. Please consider writing a Letter to the Editor or submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
William E. Rosa, PhD, MBE, AGPCNP-BC, FAANP, FAAN
Billy Rosa is a postdoctoral research fellow in psycho-oncology at Memorial Sloan Kettering (MSK) Cancer Center, New York, and a palliative care nurse practitioner by background. He received a BSN, magna cum laude, from NYU Rory Meyers College of Nursing (2009); was valedictorian of his MSN class, Hunter College (2014); and completed a PhD and Master of Bioethics as an RWJF Future of Nursing Scholar at the University of Pennsylvania (2020). He serves on the editorial boards for the Journal of Hospice and Palliative Nursing and Journal of Pain and Symptom Management, and as a board member for multiple global health and palliative care organizations. Dr. Rosa is an International Council of Nurses Global Nursing Leadership Institute Scholar, an American Psychosocial Oncology Society Health Equity Scholar, and the International Association for Hospice & Palliative Care U.S.A. Advocacy Focal Point. He is a Fellow in the American Academy of Nursing, the American Association of Nurse Practitioners, the American College of Critical Care Medicine, and the New York Academy of Medicine.
Estés, C. P. (2020). Letter to a young activist. Maven Productions. https://www.mavenproductions.com/letter-to-a-young-activist
Paice, J. A., Wholihan, D., Dahlin, C., Rosa, W. E., Mazanec, P., Thaxton, C., & Greer, K. (2020). Palliative nursing: The core of COVID-19 care. Journal of Hospice & Palliative Nursing, 23(1), 6-8. https://doi.org/10.1097/NJH.0000000000000709
Rosa, W. E., Dahlin, C., Battista, V., Finlayson, C., Wisniewski, R. E., Greer, K., & Ferrell, B. R. (2021). Primary palliative care clinical implications: Oncology nursing during the COVID-19 pandemic. Clinical Journal of Oncology Nursing, 25(2), 119-125. https://doi.org/10.1188/21.CJON.119-125
Rosa, W. E., & Davidson, P. M. (2020). Coronavirus 2019 (COVID-19): Strengthening our resolve to achieve universal palliative care. International Nursing Review, 67(2), 160-163. https://doi.org/10.1111/inr.12592
Rosa, W. E., Ferrell, B. R., & Mason, D. J. (2021). Integration of palliative care into all serious illness care as a human right. JAMA Health Forum, 2(4), e211099. https://doi.org/10.1001/jamahealthforum.2021.1099
Rosa, W. E., Ferrell, B. R., & Mazanec, P. (2021). Global integration of palliative nursing education to improve health crisis preparedness. Journal of Continuing Education in Nursing, 52(3), 130-135. https://doi.org/10.3928/00220124-20210216-07
Rosa, W. E., Ferrell, B. R., & Wiencek, C. (2020). Increasing critical care nurse engagement of palliative care during the COVID-19 pandemic. Critical Care Nurse, 40(6), e28-e36. https://doi.org/10.4037/ccn2020946
Rosa, W. E.,. Gray, T. F., Chow, K., Davidson, P. M., Dionne-Odom, J. N., Karanja, V., Khanyola, J., Kpoeh, J., Lusaka, J., Matula, S., Mazanec, P., Moreland, P. J., Pandey S., de Campos, A. P., & Meghani, S. H. (2020). Recommendations to leverage the palliative nursing role during COVID-19 and future health crises. Journal of Hospice & Palliative Nursing, 22(4), 260-269. https://doi.org/10.1097/NJH.0000000000000665
Rosa, W. E., Krakauer, E. L., Farmer, P. E., Karanja, V., Davis, S., Crisp, N., & Rajagopal, M. R. (2020). The global nursing workforce: realising universal palliative care. Lancet Global Health, 8(3), e327-e328. https://doi.org/10.1016/S2214-109X(19)30554-6
Rosa, W. E., Meghani, S. H., Stone, P. W., & Ferrell, B. R. (2020). Opportunities for nursing science to improve patient care in the time of COVID-19: A palliative care perspective. Journal of Nursing Scholarship, 52(4), 341-343. https://doi.org/10.1111/jnu.12570
Rosa, W. E., Pettus, K. I., De Lima, L., Silvers, A., Sinclair, S., & Radbruch, L. (2021). Top ten tips palliative clinicians should know about evidence-based advocacy. Journal of Palliative Medicine. https://doi.org/10.1089/jpm.2021.0182
World Health Organization. (2020). State of the world’s nursing: investing in education, jobs and leadership. https://www.who.int/publications/i/item/9789240003279