Written: 4/1 - 4/2

The tone changed this week...

We could hear it in the voices of front line nurses all the way up to executives of care facilities and associations.

These conversations are helping us peer through the looking glass into the future and realize the actions we take now to inform and support our nurses, and healthcare professionals everywhere may be the single best thing we do to avoid stress and burnout creeping silently behind the curtain.

We're all in this together. Use today's issue to implement new strategies and reduce burnout!

- Your ANA\California Team
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Meet you at the hospital in parking garage 3B... U.S. hospitals are struggling to increase the number of staffed beds. Parking lots, parks, military ships, hotels, and dormitories are just some of the places being re-purposed to care for or quarantine patients and healthcare workers infected with COVID-19.

This is just one of many new rules and waivers of federal requirements by Centers for Medicare & Medicaid Services. CMS is also temporarily eliminating paperwork requirements, waiving the requirements for a nurse to conduct an onsite visit every two weeks for home health and hospice, paying for more than 80 additional services when furnished via telehealth, and So. Much. More. Read the full summary of regulatory changes.

A forecast based on new data analyses finds demand for beds in U.S. hospital intensive care units (ICUs) will far exceed capacity as early as the second week of April . Researchers at the Institute for Health Metrics and Evaluation predict that 41 states will need more ICU beds than they currently have available and that 11 states may need to increase their ICU beds by 50% or more to meet patient needs before the current wave of the pandemic ends.

While California appears to have the bed capacity to survive peak surge, counties like Riverside, with cases doubling every 4.7 days , need help. Projected demand for all available California beds is 12,421 out of total 26,654 available beds but available ICU beds is just 133 beds above demand, begging the question: How can hospitals share resources and beds?

Grab your needle and thread because homemade face masks and respirators are now supported by the Joint Commission. Their statement was issued this week supporting staff who bring their own PPE if healthcare organizations cannot routinely provide access to protective equipment.

However, the degree to which privately-owned masks and respirators will increase the protection of healthcare workers is uncertain. As discussed in last week's issue, this study shows penetration of cloth masks by particles was almost 97% compared to medical masks at 44%.

California has added 4,252 ventilators to its original 7,500 ventilators since the start of the pandemic, with an overall goal of adding 10,000. Yet, challenges, such as broken ventilators and the need to refurbish over 1,000 of the 4,200+ ventilators, have slowed response times.

President Trump has assured Americans that the U.S. has 10,000 ventilators in reserve, ready to ship to the hardest-hit hospitals. But federal officials neglected to mention that 2,109 ventilators are unavailable after the contract to maintain the government’s stockpile lapsed late last summer.

In response to the overwhelming ventilator shortages experienced across the U.S., federal officials released new guidelines on ventilator splitting between two patients - but only "as an absolute last resort." An open letter from Surgeon General Jerome Adams and Adm. Brett Giroir, the assistant secretary for health, includes technical guidance on how ventilator splitting can be performed strictly for two patients who are both either infected or free of the virus. They acknowledge they don't know how effective or safe the strategy is because it hasn't been tested in humans.

But shortages in medicines needed for patients placed on ventilators are also in short supply. There has been a 51% increase in demand so far this month for half a dozen different sedatives and anesthetics, but the fill rate - the rate that prescriptions were able to filled and shipped to hospitals - dropped from 100% at the beginning of the month to just 63% on March 24.

These challenges underscore concerns that hospitals could soon be faced with ethical decisions about how to prioritize which patients receive life-saving equipment.

California may be flattening the curve, but testing and results are lagging behind other states. As of March 30, approximately 86,100+ tests had been conducted in California. At least 28,704 results have been received and another 57,400 are pending. These numbers include data California has received from commercial, private and academic labs, including Quest, LabCorp, Kaiser, University of California and Stanford, and the 22 state and county health labs currently testing.

Why are we lagging? California has the same number of public health labs today as it did in 1950 - a whopping 29 labs. Two decades ago there were 40 public health labs and experts believe this is contributing to dangerous lags in processing Coronavirus tests. Read more about the history of Governors and what they've done to increase, or dismantle, funding for public health in California.


As a benchmark, pooled data from 49 countries and 45,539 nurses before the Coronavirus pandemic shows burnout is a global issue. 11.23% of surveyed nurses acknowledged burnout - a.k.a. "the enduring response to prolonged interpersonal stressors."

But during this pandemic, nurses are especially at risk for burnout because work and home stressors are so intertwined. ANA\California connected with nurses inside hospitals from Boston to California this week, each highlighting similar feelings of stress and anxiety.

"Each day we walk into the ICU knowing it will be worse than the last," said a nurse from Boston. This nurse, although now at home with respiratory issues besides testing negative for COVID-19, is happy to work in an environment where her management team is putting every available resource into informing and supporting their nurses.

From these discussions, we've compiled a short list of ideas other care facility have implemented to reduce anxiety and stress among their healthcare professionals - in order of most impact according to our conversations:

  1. Daily Coronavirus Fact Sheet
  2. Daily Resiliency Meetings
  3. COVID-19 Flow Sheets - 'if this, then that' directions
  4. Facebook Groups for Mindfulness and Counseling
  5. Virtual Sessions with Unit Social Worker and Chaplain

COVID-19 is shining a light and "exposing the cracks in our foundation," said Kimberly A. Delbo MSN RN-BC CSN CDP, Founder of Radiant & Resilient Leadership, an experienced organization providing customized organizational and leadership development services. ANA\California connected with Kimberly this week to discuss how to highlight these cracks for legislators.

What did she suggest? Debriefing our nurses to evaluate and value our nurses' responses will help us create new policies. Legislators may not be aware of the impact nursing burnout has on the entire public health system, and having data to back up our stories is important - especially as they relate to the three primary outcomes: satisfying human and psychological development, mitigating and eliminating burnout, and strengthening resilience.

Scientific studies are also giving us direction on how to alleviate the three key dimensions of nurse burnout: emotional exhaustion, depersonalization, and diminished personal accomplishment.

Here are strategies from multiple studies, with special thanks to Christopher Cinkowski BSN RN for his help compiling this information:

1. Lean into your tribe - Social support from coworkers and friends has been shown to reduce levels of emotional exhaustion and depersonalization while increasing perceived personal accomplishment. When you are at work, be patient and kind to your colleagues and check-in with them to see how they are doing. Here are five questions one wellness physician asks her

  • Do you have everything you need to be safe?
  • Do you have a strategy to protect your family?
  • What’s hardest about this right now?
  • What concerns you most?
  • How are you holding up?

Asking questions like these helps to start a conversation that not only helps the respondent but can help you to feel like you’re not alone. Social distancing can be especially hard on a profession where many members are extroverts and gather energy from social contact, so try video chatting with a close friend or relative.

2. Do the next right thing - In disaster or pandemic situations, everything can seem out of control. Anticipating shortages of PPE, neighbors and communities abiding by shelter-in-place and stay-at-home orders, and waiting on when the virus will peak are all things that we can’t control as nurses - causing fear and anxiety to develop.

So focus on the things we can control. Write your representatives to voice your need for PPE, participate in surge preparation, and protest if PPE is deficient. The COVID-19 outbreak seems like such a big monstrosity that it is hard to imagine how the little things we do can help. But breaking it down into little chunks can help us feel a sense of accomplishment and take some control back, reducing fear and anxiety.

Here is an exercise: Write down on a piece of paper one thing you are concerned about that is in your immediate environment. Then write down a simple task you can do in the next 5 minutes that will enable you to get on the course of helping solve that problem.

3. Ask for help and take time for yourself - Nurses often identify themselves as the helpers, but are often hesitant or afraid to ask for help or take time for ourselves when we are the ones struggling. Of several different types of interventions examined in a large systematic review in 2019, ones that demonstrated the greatest effect on burnout were psychological interventions, including yoga, mindfulness, and therapy to develop coping strategies. Ask your employer if they have an employee assistance program that will provide you therapy sessions to talk about everything you’ve seen.

Here are the studies for those who enjoy some 'light reading':


The World Health Organization (WHO) released new guidance on the rights, roles and responsibilities of health workers during the COVID-19 crisis, which includes key considerations for occupational safety and health. Per WHO’s guidance, “health workers are at the front line of the COVID-19 outbreak response and, as such, are exposed to hazards that put them at risk of infection. Hazards include pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence. This document highlights the rights and responsibilities of health workers, including the specific measures needed to protect occupational safety and health.”

New Statewide Hotline: 833-544-2374. In coordination with the non-profit local 2-1-1 systems, Californians now have a one-stop shop to answer their questions and get assistance during this crisis (e.g. the 2-1-1 system is able to help older Californians access grocery and medication delivery while staying at home.) Call centers are staffed 24 hours a day by trained professionals, who are able to provide guidance for unmet needs. Share this with your patients!

Hello. We're ANA\California.

We enhance the health and well-being of Californians and advance the profession of nursing by advocating for legislation, regulation, and policies. We focus on improving quality care, quality experiences, quality nurses, and the quality of our profession. We're the ANA\California Team and we're here for you. How can we help?

As the legislative cycle heats up, advocating for important issues can come down to the minute. ANA\California is using Phone 2 Action, a mobile texting and advocacy platform, to help you contact your legislators with curated messages in seconds... seriously... seconds, it's that quick. Click this link to opt-in and receive text messages from ANA\California when your fellow nurses need you most!

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-- Your ANA\California Team