COVID-19 and the Nursing Profession: Where Must We Go From Here?

                        By Jacqueline Nikpour, Lauren Arrington, Allyson Michels, and Michelle Franklin

Introduction

The COVID-19 pandemic highlights many of the fractures in our healthcare delivery systems. Shortages of testing and a lack of contact tracing have created an inadequate public health response to this crisis, leading to overwhelmed hospitals and healthcare workers, who are simultaneously managing shortages of personal protective equipment (PPE). Extended stay at home orders, while necessary to prevent disease transmission, may have severe impacts on access to needed care, such as specialty care and behavioral health services. Historically marginalized populations, such as Black and working-class communities may experience a disproportionate impact, both in terms of case numbers and the longer-term societal impact due to long-extant health disparities. While the importance of a strong public health infrastructure and care delivery systems that promote population health outcomes have long been known, the COVID-19 crisis has added a sense of urgency to these needed reforms. As we work to heal and transform our fractured health care delivery systems, nurses must be at the helm.

Nurses are well-suited to make population health decisions, address social drivers, and provide leadership in health crises such as COVID-19. Situated at the intersection of medical and social expertise, nurses provide holistic, patient-and community-centered services to promote affordable, high-quality care. Nurses have been frontline in caring for COVID-19 patients, as well as in prevention, education, and other preventative health measures to slow the spread of disease. The current pandemic has immeasurably transformed the profession -impacting the available workforce, highlighting inequities in health outcomes, and opening new opportunities in care delivery. As we begin to move forward past the pandemic and into its aftermath, the nursing profession must grapple with its future, and understand how we as the nation’s most trusted profession -now, more than ever -can be part of the solution to the long existing societal health challenges highlighted by the pandemic.

Addressing Inequities

There is a clear understanding that, across the country Black, Latinx and American Indian populations are experiencing a disproportionate level of suffering and death during the COVID-19 pandemic. Racial and ethnic inequities in access to high quality health care services existed before the pandemic and have carried over into disparities in access to COVID-19 testing and treatment (see Durbha, Holtzman, and Matula reflection). Black and Latinx communities find it harder to practice social distancing at home and at work and often face employers that do not prioritize their safety and health. While unemployment related to COVID-19 has devastated all communities, Black and Latinx workers are experiencing the highest rates. Additionally, the stress of racism predisposes many nonwhite communities higher rates of morbidity and mortality during the pandemic.

Nurses must recognize and help address the ways in which societal inequities perpetuate disparate health outcomes. While nursing education focuses predominantly on providing acute care in hospital settings, COVID-19 has shown the importance of educating current and future nurses to address health outcomes at a population level. As systematic bias plays a large role in perpetuating these disparities, we must prepare a nursing workforce educated to provide culturally relevant care and address structural determinants of health. Population health competencies, including advocating for social justice; making data-based, culturally relevant decisions in care; and, promoting high-quality outcomes for diverse populations are necessary at all levels of education. Furthermore, clinical training should prepare nurses for roles in diverse settings, and funding priorities should align with population health management and related measures.

Expanded Nursing Workforce Roles

Currently, most workforce discussions have been centered around hospital-based care, yet little attention has been paid to the public health nursing workforce. This is desperately needed to mitigate the current pandemic, address the societal health consequences that have resulted, and manage future acute and chronic population health crises. Indeed, since the H1N1 pandemic in 2009, the nation lost nearly a quarter of the entire public health workforce with no plan for refunding. Given that the majority of health department employees are nurses, it is likely that many of those eliminated were nursing positions. Despite its importance in managing the current outbreak, and its crucial role in health promotion, education, and prevention of chronic disease, public health funding accounts for just 3% of all health expenditures. In its current state, the public health infrastructure and workforce are critically underfunded, limiting their capacity to drive an effective response of surveillance, contact tracing, and data sharing, and contributing to the pandemic’s catastrophic societal effects (see Pothen reflection). Issues such as personal protective equipment and ventilator shortages may very well have been significantly lessened if the “upstream” preventative approach of a strong public health system were implemented in the early days of the pandemic.

COVID-19 may be the impetus to revive funding for a strong public health workforce. The pandemic has highlighted the need to address health needs at a population level, make timely, evidence-based decisions, and provide a unified voice in educating the public -roles that public health nurses have long been experts in. Furthermore, the societal health impacts of COVID-19 will persist long after the initial outbreak, particularly in areas of health equity. Diversion of the population health workforce to focus on COVID-19 needs has led to cuts in services such the Nurse-Family Partnership, which delivers maternal and infant care to high-risk, low-income mothers. Investments in these nurse-led services going forward will be critical to mitigating these long-lasting inequities.

Other areas exist for expansion of the nursing workforce into community-based settings. Caregivers may be more reluctant to place their loved ones in a long-term care facility, as residents are unable to leave or have visitors, and as COVID-19 outbreaks are staggeringly high. For elderly individuals who need care, the demand for home health services could thus rise exponentially. Furthermore, as many behavioral health treatments have been delayed and group-based therapies socially distanced, the demand for mental healthcare (see Neptune and Nguyen reflection) could also create more opportunities for nurses. Lastly, as the Centers for Medicare and Medicaid have expanded flexibility for telehealth services, the number of individuals able to access primary care and specialty services is likely to increase. This may open up new roles for nurses in connecting individuals to social services, coordinating care, and serving as the first point of contact for greater numbers of patients and families.

The COVID-19 pandemic has also heightened the need to transform perinatal health care with nurses at the forefront of innovative strategies to improve care and outcomes. Prior to the pandemic, there were efforts underway to reduce the U.S.maternal mortality rate, which is the highest among similarly wealthy countries. During the pandemic, pregnant women have faced extreme measures, including giving birth alone, and restrictions on doula services, hydrotherapy and ambulation during labor. Increasingly, childbearing families have sought care in the community to avoid hospital exposure to COVID-19. Nurse-midwives and public health nurses are experts in providing integrated care between home and hospital that meets the needs of childbearing families and improves outcomes. Moving forward, nursing must grow opportunities for integration of nurse-led programs and services into perinatal health care, as has been done in many countries with far better perinatal outcomes.

Primary Care and Telehealth

The importance of primary care and outpatient management (e.g.,home health) and nurses’ role in care delivery and coordination within these settings are well established. However, COVID-19 caused a collision with a surge of patients needing testing and treatment for COVID-19 in addition to baseline care needs. COVID-19 has taught us the need to keep people in the community and save hospitalizations for only those who have the most critical needs as hospitals become more dangerous for patients and healthcare workers. The risk of COVID-19 exposure in hospital and clinic settings accelerated the uptake of virtual provision of such services (see Boylston and Boisvert, Durbha, and Nguyen reflections). For example, telehealth use has surged but unprecedented demand has overwhelmed telehealth services. Nurses have provided valuable improvements to telehealth as well as evidence-based solutions to respond to this demand.

Nurse-and advanced practice registered nurse-provided telehealth has the potential to greatly expand access and quality of care. Telehealth is one way nurses can address critical unmet health needs post COVID-19 -from basic primary care to virtual hospitals for more intense treatment. In order to realize this potential, innovation on the part of nurses, public health departments, health systems, and policymakers are needed.This will also require strategic investment in nursing education to address the nursing shortage that is present and intensifying. By 2022, more than 500,000 experienced nurses are expected to retire and this is not taking into account changes to the frontline RN (registered nurse) workforce as a result of COVID-19. With the nursing shortage intersecting with this pandemic, a more substantial commitment to the nursing workforce, education, and training on virtual monitoring and treatment will be needed to address the demands and innovations. By providing virtual care, nurses can bridge geographic barriers to bringing services to patients wherever they are located.

Untapped Capacity

Furthermore, the COVID-19 pandemic has illuminated the untapped capacity from all levels of nursing roles including clinical practice, leadership, health policy, advocacy, and research. Nurses have a unique perspective and capability to translate and integrate evidence from these areas into practice. As the health professional shortage has been exacerbated by the crisis, many states have permitted full practice authority for advanced practice nurses -and these new licensure laws may lead to long-lasting change going forward. This long fought for reform has the potential to expand access to high-quality, affordable primary care, where the majority of NPs (nurse practitioners) practice. At the same time, new roles for registered nurses in primary care can strengthen primary care’s delivery of services -and this may be especially true, as burnt out hospital RNs may be seeking positions in other settings after the acute pandemic. By maximizing the capacity of the current primary care nursing workforce, services such as care coordination, referral to social resources, and addressing social determinants of health, may be more available in primary care settings and lead to higher-value care.

Another opportunity for nursing growth in the aftermath of COVID-19 is in hospital and health system leadership. Health system decisions involving PPE shortages, staffing, and health informatics require the input of frontline individuals who understand deeply the impacts of those decisions. Nursing representation on hospital and health system boards can provide invaluable insight, particularly during disease outbreaks and other population health crises.

Conclusion

The COVID-19 pandemic has made clear that our care delivery systems are fractured and lack an effective, coordinated response to population health crises. Effectively addressing these gaps, both during the immediate crisis and in the long-lasting aftermath, will require the close engagement and leadership of the nursing community. Nurses have a unique perspective on and expertise in managing infectious disease outbreaks, mitigating health inequities, addressing social drivers of health, and designing innovative, patient-centered care delivery models. These capabilities are critical –now, more than ever –to reimagining a better health care system, one where equity and population health are at the center.