Health care workers are among the heroes of the pandemic. One year in, many of us are experiencing stress, fatigue, and grief. But this can pale in comparison to the toll faced by those caring for the sick and dying on a daily basis.

On the latest episode of The Dose, we listen to the stories of one group of frontline health workers: nurses. Often dealing with inadequate PPE and staff shortages, nurses are putting their own lives at risk — and many are experiencing burnout and exhaustion.

Our guest, Mary Wakefield, takes us on a journey from rural hospitals to clinics in underserved areas, all through the eyes of nurses. Mary, a nurse with a long career in health care and public service, says the pandemic has revealed that America’s public health infrastructure is “incredibly anemic.”

Transcript

MARY WAKEFIELD: Our public health infrastructure, as many people recognize clearly now, is incredibly anemic. The largest proportion of public health workforce is comprised of nurses, and yet they are still too few.

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. We’ve now been living in lockdown for an entire year. For me, and I imagine for many of you, it’s been an emotional roller coaster, but then I stopped to think about what it has been like for people caring for those who are sick with COVID-19. What I’m feeling is nothing compared to what health care workers are dealing with.

On today’s episode, we’re going to take a look at the pandemic through the eyes of one group of health workers, nurses. Nurses play a critical role in our health care system but are sometimes overlooked. So I want to dedicate today’s show to nurses. My guest, Mary Wakefield, is a nurse, professor, and among several noteworthy positions has worked for President Obama. Most recently, she served on the Biden-Harris transition team. Mary is also a longtime advocate for nurses and a champion for their work to improve health care in rural America.

Mary, welcome to the show.

MARY WAKEFIELD: Thanks, Shanoor. It’s a delight to be here with you.

SHANOOR SEERVAI: We’re speaking at a time when people are exhausted, as I said earlier, especially health care workers. Tell me how nurses are doing? How are your colleagues feeling?

MARY WAKEFIELD: Well, as you pointed out, everyone’s feeling exhausted. The shifts that all people have had to contend in their personal lives have been significant, but now you layer on top of that individuals who go to work in a work environment that puts their health directly at risk for contracting an infectious disease. And it also potentially puts their family’s health at risk. I think that if there was a meter that measured exhaustion, I think many nurses on the front lines of this pandemic would be in the red zone, whether they’re working in a public health department or they’re working in a critical care unit.

SHANOOR SEERVAI: So I’m just guessing here, but could one of the causes of exhaustion have to do with what I’ve seen in the headlines a lot, which is that actually nationally, we have a shortage of nurses?

MARY WAKEFIELD: Well, that’s a really straightforward question. Do we have a shortage of nurses? And I would say it does not have unfortunately, a straightforward answer. Over the past year or so, past number of years rather, we’ve had periods of time when it seems like there’s been an oversupply of nurses, nurses have had challenges in finding jobs. And then there’s been periods of times when we’ve seen a real demand for more nurses. What we know for sure, Shanoor, almost all the time, regardless of cycles, is that we have a maldistribution of nurses by geography. We have shortages of nurses in certain locations, sometimes in underserved inner cities in public hospitals, sometimes in rural areas and rural hospitals across the country. And that’s almost been a steady state of undersupply, inadequate numbers of nurses practicing in our rural hospitals and practicing in some of our urban areas as well.

Because of the COVID pandemic, we’re seeing severe, almost rolling shortages that in 2020 pulsed across the country. And as the numbers of hospitalized and very sick patients increased on medical floors and in intensive care units, so too accompanying that was a need for additional medical nurses, nurses with that expertise, and a need for intensive care unit nurses, nurses with that specialized expertise. Those are not skills that you can learn in a day or in an hour to practice really effectively in that high-stress, high-demand environment. So when you start with an inadequate workforce and you layer on top of that a COVID pandemic, that’s a recipe for real challenges in delivering adequate care without burning out your nursing staff.

SHANOOR SEERVAI: You’ve started to paint a picture, Mary, of what it was like last March. I wonder how some of these overburdened nurses, people who, as you say, might’ve been asked to be learning the skills of being an ICU nurse on their feet, in the middle of a crisis. How are they doing?

MARY WAKEFIELD: Fear and exhaustion were commonplace early on, as nurses were struggling to better understand the disease and the disease processes and the care needs of their patients, and also their own potential safety. So high numbers of nurses when they were queried in surveys were indicating concern for their own personal safety that they might be at risk for contracting this infectious disease. We know that that has been borne out because CDC itself reported last fall over 156,000 health care workers who had contracted COVID. In the United States as of February 2021, about a third of the deaths of health care workers who contracted COVID at their work sites, about a third of those deaths have been among nurses. So this fear wasn’t something that was misplaced.

However, over time, nurses have acclimated and become more confident. When I talk to my rural nurse colleagues, they say the initial fear of the unknown was very hard to overcome, but they gained confidence in caring for patients over time who came in with COVID and in their own skill set. And that’s certainly made a difference.

SHANOOR SEERVAI: Before we talk about the new confidence they’ve gained, I did want to ask is the fear that nurses are experiencing different or somewhat specific when we compare it to the fear that other health care workers, doctors, are dealing with?

MARY WAKEFIELD: I don’t know that there is a difference in fear among health care workers, whether you’re talking about doctors or nurses or respiratory therapists. But I do know this: that professional group is the group of individuals who spend the most time interfacing with a patient on an eight-hour shift or a 12-hour shift. They’re the individuals who tend to spend the most time with the family members of those patients. They’re in that room or in close proximity minute by minute monitoring, assessing, engaging with family members and with that patient, planning interventions, fulfilling those interventions that a patient needs. So there’s a bond and a connectedness between that nurse, that family, that patient that I think is unique to nurses in that respect.

SHANOOR SEERVAI: Especially at the beginning of the pandemic, there was an acute shortage of PPE. How are nurses getting through these long and difficult shifts in that circumstance?

MARY WAKEFIELD: That was a crisis. In the United States, an incredibly rich country compared to so many other countries around the world, nurses in my generation, generations that have come behind me, have not had to worry about, for any length of time, a shortage in the basic personal protective equipment available to them. That’s not been a worry for health care staff. And certainly not for nurses generally in the United States, regardless of where you’re practicing. It hit hard in this pandemic when nurses did not have adequate gowns, gloves, if they were working in nursing homes, they were working in hospitals, putting them directly at risk in terms of their own safety, and also trying to prevent them from potentially being a carrier of this disease to other patients for whom they were caring. So it was a high-risk environment that we never should have been in.

That risk has certainly subsided since early in 2020, but you absolutely still hear nurses expressing concern about the need to reuse equipment, use processes that they have never had to use before in terms of recycling equipment that historically would never have been needed. So, much of that concern has been mitigated, but certainly not all of it.

SHANOOR SEERVAI: Another concern I imagine would be the fact that all states weren’t hit by the pandemic at the same time, in the same way. So there were places that experienced a shortage of nurses that then didn’t have a way of bringing in enough nurses to care for their patients. Can you talk about that problem?

MARY WAKEFIELD: Sure. Just as we saw a surge in patients, people impacted with this illness, you need to be able to surge your health care workforce right alongside of that surge in the number of individuals who need nursing care and other health care interventions. And so we saw that rolling across the country, that wave affecting different communities and then increasing the demand for nurses. What happened as a result of that? Well, in many states, the governors and state boards of nursing changed their requirements for licensure in order to allow a fast surge of nurses to move into those states. In other words, places like New York, Utah, Mississippi, governors issued executive orders and emergency procedures that allowed nurses from other states to flex into those states to help meet their patients’ needs very rapidly. Rather than having to wait weeks for a nurse to get a license in the state of New York, for example, they were on autopilot coming into those states almost. Obviously they had to have a license and there were variations in terms of how 16 or 17 governors managed this, but there were many procedures put in place that allowed nurses who had retired to come back in within a state, and that allowed nurses across state boundaries very expeditiously.

All of that makes perfect sense when you start to see telemedicine crossing state borders, for example. And when you see this uptick in need for nurses, as a result of local disasters, could be floods, hurricanes, et cetera, you need to be able to surge in nurses. State licensing laws should not stand in the way.

SHANOOR SEERVAI: When you were speaking to nurses, can you give me an example maybe of somebody who was in a state who wanted to travel to a badly hit area, but couldn’t?

MARY WAKEFIELD: Sure. I certainly heard from nurses who were waiting, waiting, willing, able to move from one state, say Kentucky, up into another state, because everybody, all you had to do was watch your nightly news and you could see where these outbreaks were occurring. And there was a cohort of nurses who were willing and able to volunteer, move into those environments, and practice. There certainly were nurses who were waiting too long when their skills and knowledge were needed immediately.

SHANOOR SEERVAI: And when we think about the immediate need for support, I want to talk about what was happening in rural communities. What’s it like for nurses who were working in remote parts of the country where many people may not have easy access to a hospital? What was the role that nurses were playing there?

MARY WAKEFIELD: A big part of rural America has shortages of health profession staff. Matter of fact, the majority of our health profession shortage areas in the U.S. are in rural areas. So you’re already starting with a thin line of registered nurses, for example. If you lose two nurses from a small community hospital, you may have lost a big proportion of your nursing staff. Every nurse matters in those environments. Many of the nurses in rural America tend to be older. There’s a higher proportion of older nurses in rural areas. And so at the start of COVID, when it looked like our older populations, and we know this to be true now, were most susceptible to this disease, becoming severely ill with it.

Nurses who tended to be older, 65, 66, who might’ve been thinking about retiring two years later, started to think about retiring immediately or within a couple of weeks because they were in that high-risk category. So you saw this migration out, and then you also saw a loss of nurses because all of a sudden they had to isolate, they were exposed to COVID and maybe contracted COVID. And again, there too, you’re seeing an erosion of the nursing staff in places where you have a very thin line. So extra stress in those communities where you didn’t have backup, and you didn’t have the capacity oftentimes to compete for traveling nurses.

SHANOOR SEERVAI: Can you take me to a scene in one of these rural hospitals or rural clinics? What was happening when there was a surge of COVID cases?

MARY WAKEFIELD: Initially, nurses were very concerned when the first patients came in, really fearful, anxious about whether or not they had the skills and knowledge to protect those patients and to care for them and to help them get healthy. They were also fearful for themselves and for their families. Once they cared for those first few patients with that diagnosis of COVID-19, they developed a confidence in their skill set. That was really important. And do you know why it was so important? Because in many cases, rural hospitals that would ordinarily transfer to major medical centers, their sickest patients, they were told by the major medical centers, “We can’t take your patient. We don’t have a bed for them. You need to keep them local. And probably in many instances, you’ll be doing the same thing for them there, and you’ll have the same capacity and technology to care for them in your rural hospital, as we have in our urban hospital.”

So nurses found themselves caring for patients that were much more acutely ill, that historically would have been transferred. They didn’t have the ability always to transfer out a patient. They didn’t have the ability to ask for more nurses to come in from their community. They relied really on the resources that they had, which was relying on each other. That team approach to care became critically important.

SHANOOR SEERVAI: Do you think that this confidence will last beyond the pandemic?

MARY WAKEFIELD: Yes, I think so. I think that nurses looking out for each other was part of the team building. You certainly heard about that in urban areas. I absolutely heard about it from rural areas. Some rural hospitals, for example, nurses would create a buddy system so that each nurse assigned another nurse to them, a nurse that would check in with them: “How are you doing? How are you feeling? How are you managing?” And who were they talking to? They were talking to a peer who was experiencing the same thing. So peer supports developed organically almost. And in some cases, directors of nursing actually stepped it up and started those peer support systems.

SHANOOR SEERVAI: I want to shift gears a little bit and talk about one of the things that has been hardest to stomach about this pandemic, which is the huge racial disparity in cases and deaths. We know now that people of color have been much worse impacted than white Americans. Could you talk about how nurses specifically have been impacted by this, both the workforce and the people they care for?

MARY WAKEFIELD: Yes. The data are clear that this pandemic has impacted people of color, people across race and ethnicity, very differently. We’re not talking about a gap and how different populations are being impacted. This is a chasm with severe impacts on American Indian, Alaska Natives, in some cases, Blacks, Hispanics, versus white populations. That’s not lost on health care providers. It’s not lost on nurses who are caring for these patients as they come through the doors. The data are showing us clearly people of color are contracting the illness more frequently. They’re dying from it more often. Health care providers, including nurses are seeing this. And it means that in real time, just as we’ve identified older people as a high-risk category, and we’ve moved vaccinations to them more rapidly, we need to look at these other categories of individuals who are being impacted more severely, and determine what needs to happen, what additional protective measures need to be pulled forward rapidly to address those populations as well.

SHANOOR SEERVAI: That’s a good pivot to what I wanted to conclude with, which is solutions. What have we learned from this pandemic about what needs to change, specifically when it comes to making it easier for nurses to do the very important work that they do?

MARY WAKEFIELD: Well, the after-action report on all of this has got to include the basics of personal protective equipment. We talked a little bit about that already, but as I said, that’s still a concern. Nurses and other health care providers in the United States should never, ever again be put in this situation where they do not have what they need to be able to protect themselves and to be able to protect all of the patients for whom they care. Never again should we see nurses put in this position, because nurses became sick as a result of it, and some nurses probably died directly as a result of it.

Going forward, we need to make sure that there’s an adequate supply. Obviously, the Biden-Harris administration is looking hard at this and actions are being taken to ensure that we can handle surges in health crises with adequate equipment, adequate hospital beds, and be able to surge the nursing workforce across state lines as we need them. So national licensure for nurses, something that needs to be talked about, or more rapidly moving to state compacts that encompass virtually all states rather than the subset of states that are participating in state compacts right now.

Mental health and support for the workforce, absolutely essential when we’ve got grief, stress, burnout that is causing nurses to talk about leaving the workforce. Surveys are showing nurses saying they want to move away from the bedside. It’s exhaustion that’s driving that. They’re saying this is not something they thought about before the pandemic, but they’re feeling it now. We’ve got to have resources locally for nurses. Good news is there are many hospitals that have stepped up, they’ve created resources for their nurses, both rural hospitals and urban hospitals, but that has to be a very high priority to provide that support for the workforce.

Hopefully we’re rounding a corner in the United States as cases are starting to fall, deaths are starting to fall, but the public has a role in this too, to get vaccinated, to wear masks, to socially distance so that less pressure is put on hospitals, on nurses in the workforce, in terms of the numbers of people for whom they care.

SHANOOR SEERVAI: Finally, Mary, you’ve already said that we’re rounding a corner. Hopefully cases and deaths are going down. More people are getting vaccinated. What is the role that nurses are playing in this vaccination efforts?

MARY WAKEFIELD: Well, great news, the schools of nursing across the country in many situations are actually fielding their nursing students into mass vaccination sites to assist with that process as part of their clinical learning experience, and also as a place for nursing students to volunteer. I went in to get my first vaccine and I was delighted when I saw four nursing students helping out in that vaccination effort. A lot of nursing schools are stepping in to help at these sites. It’s happening all over the country. And we have thousands, scores of thousands of nursing students that can be fielded from community colleges, to university settings, right into these settings. That’s happening; more of it needs to happen.

In part there’s a need for this because our public health infrastructure, as many people recognize clearly now, is incredibly anemic. The largest proportion of public health workforce is comprised of nurses, and yet they’re still too few. We’ve seen an erosion in the United States public health infrastructure over the last number of years. That has got to be built back up. We need more public health nurses. Not the same, we need more.

In the meantime, we’re having to augment, of course, in this crisis situation we’re in, with nurses from other settings, with volunteer nurses coming back in who might’ve let their licenses lapse because they’ve retired. As a matter of fact, my license has not lapsed. I still am a registered nurse and I’ll be going in and actually assisting myself. I’m getting my second vaccination in just a couple of days, and I’m going to be right in there, right along with those nursing students, administering those vaccinations. It’s an all-hands-on-deck moment across the United States. Nurses who have retired are stepping back in, nurses whose licenses have lapsed are stepping back in, nurses like me, who work in health policy, are stepping back in.

SHANOOR SEERVAI: Thank you for everything you do, Mary, and thank you so much for joining us today.

MARY WAKEFIELD: It’s a pleasure to be with you, Shanoor. Thank you.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund along with Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.

Show Notes

Bio: Mary Wakefield

Commonwealth Fund Task Force on Payment and Delivery System Reform