Lessons learned from the front lines: Washington State Nurses Association’s recommendations for other states

Lessons learned banner 2

Washington State Nurses Associ­a­tion (WSNA) repre­sents the inter­ests of more than 103,000 nurses across Washington state. Our members have been on the front lines of the COVID-19 crisis in the United States. As we work to manage a public health crisis unlike any of us has ever seen, it is our duty to share the key lessons we are learning on the ground.

COVID-19 cases are expected to increase rapidly in the United States. In King County, Washington, we’ve been at the epicenter of the U.S. outbreak. Because of this, our public health depart­ments, hospi­tals, and elected officials are building the model for how large urban areas will respond to COVID-19. 

The following are recom­men­da­tions and consid­er­a­tions that we urge other munic­i­pal­i­ties and states to take now to prepare and protect themselves for COVID-19.

Groups representing nurses have a critical function #

Public opinion research consis­tently shows that nurses are America’s most trusted profes­sion. Today, millions of people are uncer­tain what infor­ma­tion they can trust. Unions and associ­a­tions repre­senting nurses can help deliver critical public health infor­ma­tion to both our members and the general public. We also serve as an impor­tant conduit for infor­ma­tion both to and from public officials, health­care facil­i­ties and other insti­tu­tions engaged in the response. Here are basic steps we recom­mend to organi­za­tions that repre­sent nurses and other health­care workers.

Coordi­nate commu­ni­ca­tion efforts with public officials. You can reach your members more reliably and with more authority than public officials. Coordi­nate directly with your local public health officials and local elected officials and provide them with a list of all the facil­i­ties where you repre­sent nurses and/​or other health care providers. This will allow them to efficiently commu­ni­cate with the appro­priate organi­za­tions as cases move into a metro area or region.

Advocate for basic infra­struc­ture. Ask your state and/​or local public health agency to estab­lish a dedicated hotline for COVID-19 questions from health care providers.

Engage officials proac­tively. Don’t wait for govern­ment agencies. Proac­tively under­stand the steps your state and/​or local public health agencies and elected officials will take to respond to an outbreak.

Engage health care facil­i­ties early. Work with employers to ensure provi­sion of appro­priate PPE to all health care workers following CDC COVID-19 guide­lines including triage proto­cols around scarce resources.

Union advocacy #

Negoti­a­tion for safe standards. Work with employers to ensure provi­sion of appro­priate PPE to all health care workers following CDC COVID-19 guide­lines including triage proto­cols around scarce resources. Work with your repre­sented facil­i­ties to ensure a basic struc­ture is in place for nurses when employer’s imple­ment their surge capacity plans and move to a crisis standard of care – this may mean an MOU or other agree­ment for repre­sented employees covering items such as:

  • Telework or alter­nate assign­ments for high risk nurses. When possible telework or alter­na­tive assign­ments will be made avail­able for nurses or health­care workers who are of the at-risk group (older than 60 or with an under­lying medical condition).
  • Clarity of communications. Commu­ni­ca­tion to nurses or health­care workers needs to be in multiple languages and in clear, uncom­pli­cated phrasing in order to increase access to essen­tial information.
  • Notifi­ca­tion of exposure. Employers should provide all nurses or health­care workers who have been exposed to a commu­ni­cable disease with written notice within eight (8) hours of known exposure with risk assess­ment and clear direc­tion if placed in quaran­tine and access to testing
  • Paid leave for quaran­tine. A nurse or health care worker who is unable to work as a result of a workplace exposure or who is in quaran­tine status shall be placed in paid leave status with no loss of pay or accrued time off until the employee is allowed to return to work.
    Floating nurses to other facilities. Float should be staffed first by volun­teers based on skills and compe­ten­cies. Nurse’s home” collec­tive bargaining agree­ment applies while mobilized to other facility, including protec­tions, just cause, mainte­nance of benefits, wages, seniority, and malprac­tice insur­ance. Advanced notice of more than 48 hours shall be provided wherever possible prior to deploy­ment. Provide incen­tive pay and reimburse travel expenses. Training shall be provided to ensure compe­tency for area to which employee is being floated. Retain workforce in the home commu­nity whenever possible.
  • Float Nurse Training/​Assignments. A regis­tered nurse that is floated outside of his/​her regular unit/​work area should receive orien­ta­tion and training to safely care for the assigned patients. Float regis­tered nurse assign­ments must comply with the state standard of nursing practice and align with the compe­ten­cies of the float regis­tered nurse. Minimum orien­ta­tion should include: 1) correct use and fitting of personal protec­tive equip­ment; 2) geography of the work area; 3) location/​use of supplies/​equipment; 4) health­care team contact infor­ma­tion; 5) shift routines; 6) required documen­ta­tion; 7) safety proce­dures; 8) unit/area-specific proto­cols. *Consider pairing a regis­tered nurse that is experi­enced in caring for the patient popula­tion with a regis­tered nurse extender, who floats from a clinic or other unit and is less familiar with compe­ten­cies required for compre­hen­sive care delivery.
  • Adher­ence to CDC guidelines. Employers should commit to adher­ence to the Center for Disease Control guide­lines on COVID-19 virus related to the health and safety of patients, clients, families and staff.

Plan to activate workers to act as a commu­ni­ca­tions pipeline within facil­i­ties that may restrict access to non-staff at some point. 

Ensure conti­nuity and clarity for your staff. During this time, the staff of your organi­za­tion will need clarity on processes and proce­dures. As organi­za­tions respon­sibly imple­ment telework to support social distancing measures, it is critical for your staff to under­stand clear expec­ta­tions both during telework and once offices reopen. 

Steps for individual nurses #

As a nurse, you have a right to protect yourself, your patients and your commu­nity. Here are basic steps we recom­mend for every nurse. 

  • Know your employer’s sick leave policies. Don’t wait to get sick! Ask about your hospital’s plan for quaran­tined employees; best practice is to place quaran­tined or ill employees on paid admin­is­tra­tive leave.
  • Know your employer’s plan for PPE. In Washington state, we are experi­encing extreme short­ages of PPE, including masks, gowns, gloves and PAPR. Take the time to under­stand your hospital’s supply of PPE and how it will be distrib­uted during a COVID-19 outbreak.
  • Avoid cross-conta­m­i­na­tion. Ask your hospital if they will provide scrubs that will be used in the facility only to avoid conta­m­i­nated clothing going home. If not, we recom­mend bringing garbage bags for trans­porting used scrubs and trans­fer­ring them directly to the washing machine without handling directly.
  • Know the testing and treat­ment proto­cols now. We have seen signif­i­cant confu­sion about how suspected and confirmed cases should be handled. Find out the plan and proto­cols for treating both suspected and positive cases of COVID-19. Ask for the proto­cols to be distrib­uted in writing.
  • Under­stand how your facility will triage poten­tial COVID-19 patients. Will there be a separate entrance for these patients? Will masks be provided to patients who present with respi­ra­tory issues?
  • Under­stand visitor policies. Ask your hospital for a clear policy on visitors in the event of an outbreak. Ask that policies be posted in public areas so patients and families can see the policy easily themselves. Refer to CDC guide­lines to manage visitor access and movement within the facility.
  • If you are repre­sented by a union, make sure you are connected with your on-site union repre­sen­ta­tive, and sign up for electronic commu­ni­ca­tions from your union.
  • If you are not repre­sented, unions in your area are a good source for infor­ma­tion. Many unions have newslet­ters you can subscribe to even as a non-member, as well as social media and websites that can provide you with accurate infor­ma­tion during this time.

Washington state may have the most advanced and serious outbreak in the United States, but the likeli­hood of signif­i­cant outbreaks is possible in every commu­nity. It is not too late to avert adverse case scenarios, but we must act quickly and follow public health orders, we must act with resolve, and we must act together.