Washington State’s nursing workforce in the context of COVID-19: Do we have a nursing workforce to meet the challenge?

By Sofia Aragon, JD, BSN, RN, Executive Director, Washington Center for Nursing

March 23, 2020

With the UW Center for Health Workforce Studies, the WCN is releasing a series of reports about the characteristics of the state’s supply of nurses. The first to be released is entitled Washington State’s 2019 Registered Nurse Workforce. Soon to follow are similar reports on Licensed Practical Nurses (LPNs) and Advanced Registered Nurse Practitioners (ARNPs). In the midst of COVID-19, what questions do these survey results raise in terms of the nursing workforce’s ability to respond to emergencies?

As the state’s nursing workforce center, we have a privileged position in the nursing community. Our network of nursing organizations such as the WA State Nurses Association, the Northwest Organization of Nurse Leaders, the Council on Nursing Education in WA State, nursing unions, nurse practitioners, ethnic nurses associations, school nurses, public health nurses, the state board of nursing, and others provide the WCN with a bird’s eye view of how nurses are responding to COVID-19.

The crisis in our state began in a long- term care facility called Life Care in Kirkland, WA. The Centers for Disease Control published a Morbidity and Mortality Weekly edition on March 18th in response to events at this facility. According to the 2019 RN report, only 9.6% of the state’s registered nurses (RNs) work in long-term care. The state of WA passed legislation to increase the number of RNs working in long-term care facilities on a 24-hour basis. However, long-term care organizations have struggled to recruit the necessary RNs. In a 2018 survey of RNs done by UW and WCN, long-term care nurses reported tending to feel more overwhelmed at work, with hospitals at a distant second.

LPNs have long been both critical staff and leaders in the long-term care system. While we await the results of a survey of LPNs, we expect to see a trend we’ve been seeing for over a decade: a steady decrease in the numbers of LPNs of about 1,000 per year. WCN is committed to further studying and elevating the role of the LPN workforce moving forward.

Meanwhile, the public hears of efforts to conserve hospital resources for those with the most acute care needs. Fifty-six percent of WA’s RN workforce are employed in hospitals. Despite being the major employer, hospitals are having to boost recruiting efforts. This raises the question of surge capacity. The American College of Emergency Physicians (ACEP) defines surge capacity as the ability to manage a sudden influx of patients. It depends on a well-functioning incident management system and the variables of space, supplies, staff, and any special considerations such as contaminated or contagious patients. Surge capacity needs to be measurable (ACEP, 2017). Reports of COVID-19 response not only highlights challenges in meeting patient care needs but also system gaps that put nursing staff at risk. A sad example is the shortage of protective personal equipment and tests for the virus.

A balance of population health and community-based strategies, as well as a strong acute care system, are needed to effectively manage a pandemic response. Alarmingly, only 1% of RNs work in public health. Public health is the science of keeping our communities and populations healthy. Most relevant to the current situation, public health nursing keeps communities and populations healthy through disease prevention and response, disaster response, and emergency preparedness. Persistent and severe funding gaps in the public health system are now apparent to lawmakers, resulting in $225 million in emergency expenditures for COVID-19 response during the 2020 legislative session.

Only 5.5% of RNs work in community health, the majority of whom are school nurses. While schools are closed in response to COVID-19, there continue to be medical and health needs for children in school-based childcare. In addition, school nurses are proactively planning for school re-opening and the development of policies to improve school health as a result of the COVID-19 experience. Examples are:

  • Coordinating with the national Centers for Disease Control and Prevention on adopting consistent public health messaging to students, parents, and staff
  • Checklists and protocols for daily self-screening of staff prior to returning, guidance for staff over the age of 60 with or without underlying health conditions
  • Nutrition-related safeguards and precautions. Examples are shared utensils for salad bars, sneeze guards, hand sanitizing stations available at cafeteria entrances
  • Messaging on social distancing and other safeguards when restarting extracurricular activities such as sports, drama clubs, and other activities
  • Guidance for teachers and specialists (occupational therapy, physical therapy, paraprofessionals, music teachers, PE teachers and others) to be cognizant of students who may be reporting or exhibiting symptoms during the school day

With health care facilities giving their undivided attention to COVID-19 response, nurse educators and nursing students are faced with the sudden halt of clinical practice sites, which threatens timely graduation and licensure of graduates, further exacerbating immediate nursing workforce needs to respond to the pandemic. The state’s board of nursing, the Nursing Care Quality Assurance Commission, is working with nursing education to encourage nursing students to register as nurse technicians. This enables nursing students to assist with nursing duties up to their level of education and documented skill level, under the supervision of a qualified RN. After graduation, students are also encouraged to apply for emergency interim permits allowing the applicant to work as a nurse during the declared emergency.

In an increasingly global community, assessing the capacity of the nursing workforce becomes complex. COVID-19 response is one example of the need for a nursing workforce that is responsive to health challenges both at times of peace and at times of emergency. Having sufficient numbers of nurses is only part of the solution. The nursing workforce must also be equipped to handle the range of challenges presented.

COVID-19 has demonstrated nursing’s role in a variety of areas that directly impact the quality of prevention and response efforts:

  • Strengthening infection control and prevention in long-term care and other facilities
  • Care of persons with chronic underlying medical conditions
  • Identifying and potentially excluding infected staff members and visitors and identifying exceptions
  • Management of supply chain issues that impact the availability of personal protective equipment
  • Taking steps now to develop or strengthen population strategies such as consistent adoption of policies to address health needs of populations like the elderly or children in the school environment
  • Implementing health technology such as telemedicine to provide care and conserve the use of PPE and predominantly facility-based services
  • Regulatory strategies to address disruption in nursing education and allowing properly credentialed out-of-state nurses to work in WA to increase response capacity

As the largest profession, RNs are positioned to work with experts and communities to develop and initiate effective responses, evaluate the effectiveness of strategies, and to provide public education on the importance of adopting effective measures into daily living. In addition to sufficient numbers of nurses, supporting their role to take action to plan for, prevent, and address situations like COVID-19 response is an indicator of a nursing workforce that can meet health challenges facing communities.

Reference: American College of Emergency Physicians. (2017). Health Care System Surge Capacity Recognition, Preparedness, and Response. Retrieved from https://www.acep.org/patient-care/policy-statements/health-care-system-surge-capacity-recognition-preparedness-and-response/

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