VA AND MHS NURSES RESPOND TO PANDEMIC CHALLENGES

By Gail Gourley

It’s difficult to overstate the impact of the COVID-19 pandemic on nurses, from those who work directly with the sickest of the virus’ victims to those who provide needed care in myriad other ways in all patient settings. More than a year into the pandemic that threw everything familiar into uncharted territory, nurses everywhere, including those in the Department of Veterans Affairs (VA) and the Military Health System (MHS), have continued caring for patients with courage, compassion, and expertise under circumstances that require perseverance, creativity, and commitment.

U.S. Army Spc. Sarla Dominguez, licensed vocational nurse, teaches electrocardiograph procedures and placement to nurses in Tier 2 Nurse Training at Brooke Army Medical Center, Fort Sam Houston, Texas, April 23, 2020. The Center for Nursing Science and Clinical Inquiry, the Department of Hospital Education and Training, and the 3 West staff were providing the training to sharpen the skills of outpatient nurses who might have to transition to inpatient nurses in the event of a patient surge due to COVID-19. MHS nurses have continually adapted to meet the needs of patients during the pandemic.

Beth Taylor, DHA, RN, NEA-BC, Veterans Health Administration (VHA) chief nursing officer, quickly used the word “challenging” to describe the pandemic’s impact on VA nurses. “It was an unexpected challenge for us this past year; one that was intense, one that was unrelenting for a period of time,” she said. “But as I think about the response nurses had to the pandemic, the words I would use are ‘resilient,’ ‘resourceful,’ ‘courageous,’ ‘innovative,’ ‘committed to the mission,’ ‘compassionate for the work to be done.’ Another word that I would add is ‘pride’ – pride in their work and pride of the organization, of the work of all clinicians and all staff as we responded to this pandemic.”

“I would echo that, and say ‘dedicated,’” added Jessica Bonjorni, MBA, PMP, SPHR, VHA chief of human capital management. “Our nurses are always dedicated, but they stuck it out and really stepped up to the plate in their response to COVID-19 to make sure that we could be successful.”

VA NURSES RESPOND

The responses to the pandemic’s demands were multi-faceted. VA nurses worked more shifts, longer hours, cross-trained, and more, according to Taylor. For example, from March 2020 to date, she said, “Over 3,500 VA nurses have deployed, either internal to VA to support the pandemic response, or external to VA on our ‘Fourth Mission’ assignments [supporting state and local health care systems]. They supported state veterans homes, community nursing homes, and other federal agencies such as the Indian Health Service, and deployed to remote regions of the country to assist. That 3,500 nurses were willing to [deploy] is phenomenal in my view.”

Michelle Cummins, a registered nurse at the West Texas VA Health Care System and an Army nurse veteran, dons personal protective equipment before heading into a mobile intensive care unit at William Beaumont Army Medical Center in El Paso, Texas. Cummins deployed to El Paso to assist in efforts to handle a high number of COVID-19 cases there. Approximately 3,500 VA nurses have deployed around the country to support the pandemic response.

Many nurses engaged in additional training so they could migrate to either a medical-surgical unit or an intensive care unit as needs evolved. “For example,” Taylor said, “we had several nurses that worked in primary care clinics or specialty clinics that engaged in additional continuing education and said, ‘Yes, I will go to the bedside where the COVID patients are, or where other patients that are non-COVID are.’ Where resources were needed, they went to the bedside to assist those other staff.”

Elaborating on other staffing efforts, Taylor identified utilization of contract nurses, as well as a team effort with Workforce Management and Consulting to augment the existing VA Travel Nurse Corps to further enhance agility in addressing staffing needs nationally.

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Bonjorni emphasized, “As the largest integrated health care system in the U.S., the VA is able to shift its workforce across the country, including both the Travel Nurse Corps and staff who volunteered for deployments in areas of greatest need. It is a great benefit of our health care system that we can shift those resources when needed.”

ADDITIONAL VA STAFFING EFFORTS

But clearly, additional hiring to meet increasing needs would be essential. “That was important for us to really boost our hiring,” Bonjorni said, “and we started with a challenge from our leadership to try to get our hiring timelines down to a very, very quick pace. We had excellent partnerships across the department and also with OPM [Office of Personnel Management] and others to help us get some flexibilities on a temporary basis to speed up our hiring process.”

Efforts ranged from hiring fairs, targeted marketing, and direct outreach to retired employees, for example. “We changed around our internal processes to make it quicker to bring people on board,” Bonjorni said, “so that we can front-load the process and get nurses on board quickly, and then follow up with any of the things that we normally do in the pre-employment process. Some of those are things we’re trying to get extended in the long term. Some will require help from external agencies and entities to get additional policy or regulatory or legislative changes. But we are working through those.”

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Additional efforts to recruit and retain new hires included leveraging existing authorities to provide group incentive awards, especially in locations with significant private-sector competition for nurses, Bonjorni said, as well as enhancing existing childcare support by expanding the income range eligible to receive funds for covering childcare costs. “We need to do everything we can to support our employees so that they can come to work with as few external stressors as we can help them with,” she said.

From March 2020 through February 2021, Bonjorni said the VHA hired 15,431 registered nurses (RNs), 1,065 nurse practitioners, and 137 certified registered nurse anesthetists.

Denise Dulude, a nurse at the VA for 37 years, retired in January 2020, only to return to work at the VA Boston Healthcare System in April to assist with the VA’s COVID response. The VA boosted hiring to meet increased demand during the pandemic, reaching out to retired employees, holding hiring fairs, and adjusting internal processes to bring new hires onboard more quickly.

“It was really inspiring to see the number of people that wanted to step in and help out with our mission in caring for veterans during this time,” Taylor said.

Success metrics of the combined efforts also include a decreased RN loss rate. “In fiscal year ’20, our loss rate was about 7.9 percent, under 8 percent, which is really good compared to industry standards, and our loss rate so far in fiscal year ’21 is 7.2 percent. I think it speaks to some of the words we used in the very beginning, of commitment and resilience, but also I think it speaks to success in some of the authorities that Jessica was describing, successfully addressing some of the needs of our nursing workforce and retaining them,” Taylor said.

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With the very real pandemic-enhanced potential for burnout and fatigue among nurses constantly present, Taylor said they monitor data on a national level from employee surveys and standardized industry tools to assess burnout and gauge nurses’ satisfaction with their work environment. She noted that “the scores for overall satisfaction are up year-over-year from last year in data collected in the fall of 2020.”

As an example of the importance of supporting staff wellness, Taylor highlighted a whole health program designed in a partnership between the Office of Nursing Services and the Office of Patient Centered Care and Cultural Transformation. Nurses can participate in facilitated, virtual sessions that include mindfulness, meditation, relaxation, and breathing exercises “to give people a time to collectively pause together and support each other,” she said.

LASTING EFFECTS

Asked about the likelihood of longterm effects that the pandemic might have on VA nursing, Taylor predicted a continued strengthening of working relationships with other clinical disciplines and medical staff.

And while the VA has long been at the forefront of virtual care and telehealth utilizing a variety of modalities, Taylor emphasized that pandemic adaptations resulted in a “huge surge” in the amount of virtual and home care provided. “I think it will forever change us in terms of the care that we provide face to face versus assessing the care that we can provide virtually,” she said.

From her perspective, Bonjorni expressed her belief that the new innovative recruitment processes and procedures will change the way that VHA brings top-quality nurses into the workforce. “I think it’s going to really challenge us to make sure that we are being flexible in our hiring policies and practices, so that we’re being swift and thinking differently about how we do that business,” she said. “From an overall recruitment and retention perspective, I think that we demonstrate ourselves as a model employer in that even when you see a lot of turbulence in the health care marketplace that happened over the course of the pandemic, where in the private sector, they were in some places laying people off or furloughing them, or cutting their pay because of economic concerns, we did not do that, and we were in fact increasing our on-board strength.”

Bonjorni added, “I am in awe of our nursing workforce. They have really shouldered the bulk of this burden over the course of more than a year now. And really, I am grateful. So my message to them is, ‘Thank you.’”

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Taylor reflected on the irony that 2020 was the International Year of the Nurse and Midwife acknowledging the 200th anniversary of Florence Nightingale’s birth, and that “we had this global pandemic in which nurses were really the ones that were most relied upon in terms of staffing our units and responding to COVID,” she said. “I think it’s interesting that nursing had an opportunity in that year to demonstrate its heroic efforts in addressing this pandemic and the key role it plays as the backbone to our American health care industry.

“I’ve always been proud of being a VA nurse, and proud of the mission,” Taylor concluded. “I think our mission is second to none. But this past year, I couldn’t be more proud of the efforts of our nursing corps in addressing the pandemic, and I’m so inspired by the work that they have led and continue to lead on behalf of our nation’s veterans.”

A MILITARY HEALTH SYSTEM NURSE’S COVID-19 PERSPECTIVE

Nurses within the MHS also confronted pandemic-related challenges in inpatient and outpatient settings, requiring continuous adaptation and innovation.

“Caring and providing services for our patients has always been the priority and mission, but the pandemic added many challenges in managing the health of the force with the health of those we serve,” offered Meredith Myatt, CPT, AN, detachment commander and clinical nurse officer in charge (CNOIC) of the Readiness Section at Andrew Rader U.S. Army Health Clinic. This outpatient clinic at Joint Base Myer-Henderson Hall, part of the National Capital Region (NCR) Market, delivers primary, pediatric, and specialty care services to soldiers and families.

U.S. Air Force Capt. Jodie Cantey, a clinical nurse with the Delaware National Guard’s 166th Medical Group, talks with a motorist during a drive-thru coronavirus testing mission at Georgetown, Delaware, June 10, 2020. About 25 National Guard members supported the saliva-based testing of more than 200 people there. Nurses with both the Military Health System and the Department of Veterans Affairs took on new responsibilities – including administering COVID tests – to respond to the coronavirus pandemic.

Elaborating on some of the challenges, Myatt continued, “Throughout the pandemic, critical decisions have had to be made regarding essential care for patients. We have had to adopt new practices, get used to unfamiliar ways of delivering care, and find ways to safely deliver necessary face-to-face care. For example, the immunizations clinic delivers essential vaccines to infants and children at the most vulnerable ages, and we knew that was something we were committed to continuing. The challenge came in determining how to deliver this care while keeping our team safe.”

MHS nurses have been integral to the provision of care related to COVID-19, but they have also ensured that patients continue to receive routine medical care, such as immunizations or prenatal checkups, during the pandemic.

Myatt explained that the immunizations nursing team responded to that need by grouping critical appointments by like-patients, when “infants and young children were provided care on separate days from that of the adult population. We also limited the amount of people within the treatment areas and moved to an appointment-only process in order to control the flow of patients within the clinic and section.”

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Providing other examples of nurses’ adaptations, Myatt added, “We all quickly learned to do more with less. Compared with many of our sister medical treatment facilities in the area, our clinic is considerably smaller. Despite our size, our patients continued to rely on us for safe and efficient care throughout the pandemic. We were forced to get creative with how we accommodated these appointments and services with new spacing constraints.

“We also learned shared responsibility. Nurses stepped up and took on roles as COVID-19 screeners, runners, testers, and coordinators. Some adapted to providing care virtually and others took on new roles altogether, such as contact tracing. We were presented with new roles and opportunities to excel in caring for our patients. The COVID-19 outdoor screening and testing area was designed and executed in part by the nursing team within Rader Clinic, and has successfully completed numerous tests for patients and beneficiaries in the NCR. The COVID vaccine clinic began the operation with a team of just five personnel. We were able to adapt and successfully administer vaccines to emergency responders, medical personnel, frontline essential workers, and those at highest risk for severe illness from COVID-19. We continue this enduring mission and our team has grown; many stepped up and volunteered to support, knowing the importance of vaccinating our community. We all feel this is one way to give back and contribute to the resolution of the pandemic.”

With new roles and constant necessary adjustments increasing the potential for stress and fatigue, Myatt indicated that she and her team found that shared acknowledgement and understanding of burnout was the most effective way to deal with it.

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“Nurses tend to run on fumes and refuse to admit we need a break,” she acknowledged. “No one knew how long this was going to last, and I don’t think any of us could have imagined its impact. When we realized this was a marathon, our team decided to set aside time to discuss coping strategies, stress relievers, and some of our greatest challenges. We realized we were all feeling the same stress, and the shared understanding of the weight of our role became a huge help in implementing additional coping mechanisms. The clinic commander coordinated training and implemented town halls to deliver information and keep everyone abreast of the pandemic, our responsibilities, and the resources available to us.”

MAKING AN IMPACT

Myatt shared that her biggest surprise has been the impact she’s been able to make in her role as an outpatient nurse. “Initially it was difficult to watch some of my peers in inpatient facilities who were in the thick of things working tirelessly on a daily basis on COVID-19 units with extremely sick patients,” she reflected. “As a trained inpatient nurse, it felt like I wasn’t doing enough and my role in the outpatient setting didn’t have an impact. I quickly realized that wasn’t true, and that my patients needed me, too.

A VA nurse administers a COVID vaccine at the VA Southeast Louisiana Veterans Health Care System in New Orleans. VA and MHS nurses are a vital part of the effort to vaccinate the population.

“Whether it was screening and testing for COVID-19 to ensure treatment and containment of the virus, or vaccinating vulnerable infants and children against other threats, my role was still important,” she continued. “I also felt like every patient we could keep healthy was one less patient that would have to seek additional care at another medical facility, and potentially one less patient that would suffer from this tragic virus.”

Asked about her message to her patients, Myatt emphasized, “Education is key! As a nurse, it is my duty and greatest pleasure to be able to educate myself and my patients. We are most afraid of what we don’t understand, and this was new for all of us. My patients look to me for answers and understanding. The virus and all of its uncertainty is what caused the most anxiety and stress for all of us. If you can do nothing else, take the time to understand what the virus is, what you can do to prevent its spread, and how the vaccine is key in getting us back to normal. Just as I felt comfort in knowing that what I did mattered, I encourage my patients that they too can be part of the solution. We can all contribute one vaccine at a time.

“This time is temporary, and we will get through it,” Myatt concluded. “We face difficult times in life that shape us, but they don’t have to break us. I believe this year has made me a stronger nurse, and for that I am grateful.”