Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients.

One factor potentially driving healthcare and hospital worker (HHW)'s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others' pandemic-related responses and behaviors. We investigated whether HHWs' betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

Day to Day and Environmental Risk Factors for Psychological Distress Among Healthcare Workers: A Mixed Methods Analysis.

OBJECTIVE: Despite a growing literature on mental health among clinical staff during COVID-19, factors shaping distress for nonclinical staff are understudied and may be driven by inequalities at work. We aimed to discuss the role of workplace factors in shaping psychological distress for a diverse group of clinical, nonclinical, and other health and hospital workers (HHWs). METHODS: This convergent parallel mixed-methods study with HHWs in a US hospital system included an online survey ( n = 1127) and interviews ( n = 73) collected from August 2020 to January 2021. We thematically analyzed interviews; findings informed log binomial regression estimating risk factors for severe psychological distress (Patient Health Questionnaire - 4 item version [PHQ-4] scores of 9 or greater). RESULTS: Qualitatively, day-to-day stressors fostered fear and anxiety, and concerns about work environments manifest as betrayal and frustration with leadership. Distress was associated with burnout, financial concerns, and feeling betrayed or unsupported by the institution and leadership. Staff in service versus clinical roles had higher risk for severe distress (adjusted prevalence ratio = 2.04, 95% confidence interval = 1.13-2.66); HHWs receiving workplace mental health support had lower risk (adjusted prevalence ratio = 0.52, 95% confidence interval = 0.29-0.92. CONCLUSIONS: Our mixed-methods study underscores how the pandemic brought inequalities to the surface to increase distress for vulnerable HHWs. Workplace mental health activities can support HHWs now and during future crises.

Analysis of trends in nurse practitioner billing for emergency medical services: 2015-2018.

STUDY OBJECTIVE: Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. METHODS: Medicare provider utilization and payment data between 2015-2018 was used to explore NP billing as compared to five other clinician provider types for common emergency services acuity codes (CPT codes 99281-99285) to determine services billed for levels of severity of illness and trends over time. Number of services billed by clinician provider type related to state policies on NP practice authority, location, and population characteristics was explored. RESULTS: NPs who independently billed for ED CPT codes (99282-99285), increased during this time and decreased for acuity code 99281 (minor and self-limiting). Overall, NPs saw a greater increase than all other providers in both the highest severity CPT codes of 99284 and 99285. The analysis revealed that type of clinician, state practice authority policy, number of NPs, and percent of population 65 years and older (by zipcode) and population size are positive predictors for services billed. The negative predictors were rurality, states which accepted the Medicaid expansion, having a higher number of non-English speaking residents, and non-emergency medicine clinicians. CONCLUSION: As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.

Radiation Injury Treatment Network Medical and Nursing Workforce Radiation: Knowledge and Attitude Assessment.

OBJECTIVES: The Radiation Injury Treatment Network (RITN) is prepared to respond to a national disaster resulting in mass casualties with marrow toxic injuries. How effective existing RITN workforce education and training is, or whether health-care providers (HCPs) at these centers possess the knowledge and skills to care for patients following a radiation emergency is unclear. HCP knowledge regarding the medical effects and medical management of radiation-exposed patients, along with clinical competence and willingness to care for patients following a radiation emergency was assessed. METHODS: An online survey was conducted to assess level of knowledge regarding the medical effects of radiation, medical/nursing management of patients, self-perception of clinical competence, and willingness to respond to radiation emergencies and nuclear events. RESULTS: Attendance at previous radiation emergency management courses and overall knowledge scores were low for all respondents. The majority indicated they were willing to respond to a radiation event, but few believed they were clinically competent to do so. CONCLUSIONS: Despite willingness to respond, HCPs at RITN centers may not possess adequate knowledge of medical management of radiation patients, and appropriate response actions during a radiation emergency. RITN should increase the awareness of the importance of radiation education and training.

Alignment of Nurse Practitioner Educational Preparation and Scope of Practice in United States Emergency Departments: A Systematic Review of the Literature.

INTRODUCTION: National debate persists surrounding the expanded use of nurse practitioners in the emergency department. Current understanding of the alignment of nurse practitioner educational preparation and practice parameters in United States emergency departments is inchoate. The objective of this review was to seek evidence to support that nurse practitioner education and training align with current practices in the emergency department. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided systematic review of the existing literature was conducted of 4 relevant databases. Level of evidence and quality assignments were made for each article using Grading of Recommendations, Assessment, Development, and Evaluation or Confidence in Evidence from Reviews of Qualitative Research as appropriate. RESULTS: Nurse practitioners are increasingly staffing emergency departments, providing care to both patients classified as high-acuity and low-acuity. Reports of nurse practitioner scope of practice vary widely. No studies evaluated alignment of educational preparation and training for actual clinical practice. DISCUSSION: This review of the literature was inconclusive, and the review team we was unable to find evidence that supports the alignment of nurse practitioner educational preparation and training with scope of clinical practice in United States emergency departments. Future research should seek to articulate the landscape of nurse practitioner academic preparation for specialty practice in the emergency department and to specifically examine the alignment of educational preparation with scope of practice and impact on clinical outcomes of patients seen in the emergency department.

Exploring National Nursing Readiness for a Radiological or Nuclear Incident: A Cross-Sectional Study.

INTRODUCTION: As the largest component of the United States health care workforce, nurses will play a critical role in radiological or nuclear disaster medical response. Despite this, the United States' schools of nursing are not currently providing radiation content (75% teach zero or <1 hour), and much of the current nursing workforce may not have received adequate response education and training. Nurses working in emergency departments and those who work at hospitals within the Radiation Injury Treatment Network will be relied on heavily, but little is known about whether these nurses possess the knowledge and skills needed to care for and protect patients after a radiation emergency. Current federal and state radiological/nuclear preparedness plans may be built on false assumptions of readiness, which would have serious implications for national preparedness and the National Health Security Strategy. The purpose of this study was to assess nurses' knowledge and skill in emergency radiological or nuclear response and determine their willingness to use mobile technology for education and training in response to a large-scale radiation event. METHODS: Descriptive cross-sectional survey of registered nurse members of the Emergency Nurses Association and/or those employed at Radiation Injury Treatment Network centers. RESULTS: Knowledge scores were low for all respondents. Prior attendance at a Radiation Emergency Medical Management course, use of online resources, and having a preparedness plan were associated with higher scores. Experience with a radiation emergency was associated with the highest score. Nurses are willing to use mobile technology during a radiological or nuclear disaster response. DISCUSSION: Key nurses may not possess adequate knowledge or clinical competence to participate in radiation response activities. The results of this assessment identified educational gaps and areas to strengthen nursing education and clinical skills.

National Assessment of Nursing Schools and Nurse Educators Readiness for Radiation Emergencies and Nuclear Events.

Nurses will play a crucial role in responding to a public health emergency resulting from nuclear war or other large-scale release of radiation into the environment and in supporting the National Health Security Strategy. Schools of nursing are ultimately responsible for developing a competent nursing workforce prepared to assess a population's public health emergency needs and respond to these low-frequency but high-impact events. This responsibility includes the provision of specific content and training regarding how to respond and care for patients and communities in the event of a nuclear or radiation emergency. To date, however, there has been a lack of empirical evidence focusing specifically on nursing schools' capacity to prepare nurses for radiation emergencies and nuclear events, as well as perception of risk. This study employed a cross-sectional survey administered to a nationwide sample of nursing school administrators and faculty to assess content, faculty expertise, planning, and perception of risk related to radiation emergencies and nuclear events.

Analysis of Emergency Health Care Workforce and Service Readiness for a Mass Casualty Event in the Republic of Ireland.

OBJECTIVE: Ultimately, a country's capacity for a large-scale major emergency response will be directly related to the competence of its health care provider (HCP) workforce and communication between emergency responders and hospitals. The purpose of this study was to assess HCP preparedness and service readiness for a major emergency involving mass casualties (mass casualty event or MCE) in Ireland. METHODS: A cross-sectional study using a 53-item survey was administered to a purposive sample of emergency responders and HCPs in the Republic of Ireland. Data collection was achieved using the Qualtrics® Research Suite. Descriptive statistics and appropriate tests of comparison between professional disciplines were conducted using Stata 13. RESULTS: A total of 385 respondents, registered nurses (43.4%), paramedics (37.9%), medical doctors (10.1%), and administrators/managers (8.6%), participated in the study. In general, a level of knowledge of MCEs and knowledge of clinical response activities and self-assessed clinical competence varied drastically across many aspects of the survey. Knowledge and confidence also varied across professional disciplines (P<0.05) with nurses, in general, reporting the least knowledge and/or confidence. CONCLUSIONS: The results demonstrate that serious deficits exist in HCP knowledge, skills, and self-perceived abilities to participate in a large-scale MCE. Results also suggest a poor knowledge base of existing major emergency response plans. (Disaster Med Public Health Preparedness. 2019;13:243-255).

National nurse readiness for radiation emergencies and nuclear events: A systematic review of the literature.

BACKGROUND: Little is known regarding the capacity of U.S. nurses to respond following a large-scale radiation release, despite its relevance to our National Security Strategy. PURPOSE: To conduct a systematic review of the literature to assess nurse readiness for radiation emergencies and nuclear events. METHODS: A systematic review of publications identified through a comprehensive search of four relevant databases (Embase, PubMed/Medline, Scopus, and Web of Science) was conducted (n = 62). FINDINGS: Limited evidence exists to support that nurses are prepared or willing to respond to a large-scale emergency resulting from a radiation release or nuclear-level event. DISCUSSION: History suggests nurses will be expected to perform triage, minimize radiation exposure, decontaminate, manage trauma, treat burns, and coordinate care for patients. Research is needed to identify the specific roles and responsibilities of nurses in radiation emergencies and nuclear response and to ascertain quantitative measurement of the level of national nurse readiness for these large-scale radiation emergency and nuclear events.