How effective response to COVID-19 relies on nursing research.

Abstract

In the weeks as the COVID-19 health crisis unfolded, several challenges to responding effectively became evident. I focus on three of these challenges to illustrate how nursing research provides answers during crises: restricted access to health care, surging demand for health care personnel, and the moral distress that health care providers face. To limit virus transmission, most ambulatory providers converted to telehealth encounters instead of in-person encounters. To facilitate this change, an early policy response to the coronavirus by the Centers for Medicare and Medicaid (CMS) expanded the number of services that would be reimbursed when furnished via telehealth (Centers for Medicare and Medicaid, 2020). The field of telehealth first emerged as an approach to expand access to patients in remote settings. Fathi, Modin, and Scott (2017) reviewed the emergence of telehealth in the United States and how it increased health care access. There is a solid record of nursing research providing evidence on the comparative effectiveness of telehealth. A systematic review and meta-analysis synthesized 43 studies comparing telehealth interventions delivered by registered nurses (RNs) and allied health professionals with standard face-to-face interventions (Speyer et al., 2018). The research showed that telehealth may be as effective as face-to-face. The influx of patients with COVID-19 symptoms into hospitals requires more health care providers than usual due to the high fraction of hospitalized COVID-19 patients requiring critical care and the time-consuming regimen of donning and working in personal protective equipment. Here, an effective response combines national and institutional initiatives. Swift action by Centers for Medicare and Medicaid (2020) reduced physician supervision requirements over nurse practitioners, certified registered nurse anesthetists, and physician assistants. This practice at the “fullest extent possible” of these advanced practitioners has been well supported by empirical evidence (Institute of Medicine, 2011). Such expanded use of these advanced practitioners increases available health services by them directly as well as by reducing physicians' supervision responsibilities. At the institutional level, how can hospital managers respond effectively to surging health care demand? Nursing research demonstrates that care settings value professional nursing knowledge and skill achieve better patient outcomes (Aiken et al., 2011; Lake et al., 2019). In these settings, nurses are expected and supported to fully utilize their knowledge and skill, to coordinate care within the health care team, including physicians, respiratory therapists, and unlicensed assistive personnel, and to be partners in planning for disaster response. A key institutional metric is the staffing level of RNs. The research evidence is consistent that better-staffed hospitals achieve superior patient outcomes (McHugh et al., 2016; Shekelle, 2013). Multiple, rigorous studies have documented lower patient mortality in hospitals with better educated RNs (Aiken et al., 2014; Kutney-Lee, Sloane, & Aiken, 2013). Enlightened hospitals have been recruiting nurses with a Bachelor of Science in Nursing (BSN) degree or encouraging their RNs who entered the profession with an Associate or Diploma degree to complete the BSN. Therefore, hospitals can best prepare for a pandemic-related surge by establishing safe staffing levels, professional environments, and high educational expectations for their RNs. Even in a well-staffed hospital with a supportive professional environment, aspects of COVID-19 disease confront health care providers with unique risks and emotional strain. Because the virus is highly contagious, health care providers face constant worry for themselves and their family members of contracting the virus. The visitor restrictions in hospitals make the health care providers the only people available to offer emotional support and comfort to all hospitalized patients during their illness and, for those who do not survive, while dying. These risks and strain present ethical dilemmas to nurses whose desire to meet their professional ethical obligations may conflict with their personal values and priorities. The ethical strain is compounded by the emotional strain. How can nursing research address this deep strain? Nursing ethics research suggests that having a positive ethical climate and institutional support for dealing with ethical issues are key elements to managing ethics stress and ethical concern (Ulrich et al., 2007). In a time of profound upheaval, risk, and strain, it is reassuring to have evidence-based solutions to the challenges confronting our health care system and its clinicians. National policy responses and institutional preparedness offer complementary approaches that have empirical support from nursing research. If the temporary regulatory changes enacted by CMS and the institutional readiness succeed during the COVID-19 pandemic, a silver lining may be their flourishing as the “new normal” in the postpandemic era.